WORLD AIDS DAY
PrEP on Demand Now an Option in New York
Alternative, approved but not recommended, geared toward daily dosing problems
Dr. Demetre Daskalakis, New York City’s deputy health commissioner.
Schematic showing the dosing approach for PrEP on Demand.
BY MATT TRACY
A daily pill known to prevent
HIV transmission
does not necessarily
need to be taken every
day, at least in some demographic
groups, according to guidelines
published by health offi cials in
New York City and elsewhere who
have found that the pill is still effective
when dosages are based on
when a person is planning to have
sex.
Dubbed “PrEP on Demand,”
men who have sex with men can
take two pills between two and 24
hours before having sex and then
another pill within 24 hours after
having sex. One more pill must
then be taken 24 hours later. If the
NYC DEPARTMENT OF HEALTH AND MENTAL HYGIENE
individual continues having sex, he
should continue taking PrEP daily
until two days after the stretch of
sexual activity ends.
A person who plans to have sex
on a Friday night, for example,
could take two pills on Friday afternoon,
another pill on Saturday,
and one fi nal pill on Sunday
— that is, if Friday is the only day
that person has sex.
Around the time of WorldPride
this past summer, the city sent doctors
and other health professionals
guidelines outlining the regimen
as an alternative option for men
who have sex with men, including
those who cannot afford the cost
of daily PrEP and those who have
sex inconsistently, have kidney
impairments, or would rather not
DONNA ACETO
take the pill every single day, according
to the city’s Department of
Health and Mental Hygiene.
“Part of that came from providers
who were trying to do PrEP on Demand
without really understanding
what the dosage schedule was
like,” said Dr. Demetre Daskalakis,
the deputy health commissioner.
“So it was an opportunity to alert
people of an alternative strategy.”
Some people informally took
PrEP on an on-demand basis even
before guidelines were unveiled.
That phenomenon was at the center
of a 2018 study evaluating daily
and non-daily dosing schedules
for PrEP among 37 men who have
sex with men in New York City. The
study found participants “generally
expressed preferences for non-daily
dosing schedules, both because
non-daily dosing corresponded to
patterns of sexual activity and because
they believed side effects of
the PrEP medication would be less
with less frequent dosing.”
But public health offi cials agree
that intermittent doses can lead to
adherence challenges in terms of
both sticking to the 2-1-1 regimen
and making sure to take it before
sexual behavior occurs.
“Remembering regular non-daily
doses was diffi cult on the timedriven
schedule; in both time-driven
and event-driven arms of the
study forecasting sex in order to
plan for dosing around sex was a
challenge,” that study noted.
Importantly, the city’s health
department still prefers that individuals
take PrEP daily, and
Daskalakis made it clear during
a phone interview with Gay City
News that PrEP on Demand is not
being recommended. The guidelines
have only been published in
certain other locations, such as
San Francisco. The Food and Drug
Administration has approved only
daily doses.
Studies evaluating the effectiveness
of PrEP on Demand have
been successful dating back several
years. A 2014 trial of PrEP on
Demand among HIV-negative men
who have sex with men in France
and Canada, called the IPERGAY
study, showed such strong evidence
in support of PrEP on Demand
that the trial ended early.
Yet, while Daskalakis noted that
PrEP for daily use is roughly 99
percent effective, he pointed out
that the percentage of effectiveness
for PrEP on Demand is somewhere
“in the mid-80s.”
Even with reduced effectiveness,
the on-demand regimen appears
to be the next best option for individuals
who refuse to adhere to
a daily schedule. Daskalakis said
he has patients who are at high
risk for HIV “but they won’t take
the pill every day.” He said he then
explains in complete detail to his
patients how to structure doses
around sexual encounters, but
that schedule proves to be far too
complex for some of them.
“I’ll get a text or a call saying,
‘I don’t know how to do it,’” he explained.
“Honestly, a pill a day is a
lot more straightforward.”
Far more research is necessary
to further understand PrEP on Demand
among other demographics
beyond men who have sex with
men. Studies have not thoroughly
examined PrEP on Demand’s
impact among transgender individuals
or cisgender women and
it is not clear when the guidelines
could expand beyond the existing
demographics.
November 28 - December 4 4 , 2019 | GayCityNews.com
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