“HIV prophylaxis PrEP must be accompanied by a doctor”

PrEP is a prophylaxis to protect against HIV infection with drugs that were originally developed for HIV therapy. In Switzerland, the application is currently not approved for pre-exposure prophylaxis. PrEP is nevertheless becoming increasingly popular, particularly among the group with the highest risk of HIV infection, homosexual and bisexual men. Due to the high cost of the original preparation, most people obtain the medication much more cheaply abroad. Benjamin Hampel, assistant physician at the Clinic for Infectious Diseases and Hospital Hygiene, on the risks and study findings.

Benjamin Hampel. The medication used for PrEP is not approved for this purpose in Switzerland, but it is nevertheless prescribed here. How does that work?

This so-called off-label use is not uncommon in medicine. It presupposes that the doctor acts according to the best of his knowledge and the current data situation and adheres to existing recommendations. In the case of PrEP, the high price of the original preparation – a combination of the two best-studied active ingredients teonfovir disoprxil fumarate and emtrictiabine – is an additional complication. Many users make do by purchasing cheaper generics from abroad. This is legal for personal use in Switzerland under certain conditions. As this is a prescription-only medication in Switzerland, you should also have a prescription. Many reputable online providers now require this for orders from Switzerland. Taking PrEP is therefore legal, but is not covered by health insurance because it is a prophylaxis.

Where can I order this from Switzerland?

There are online providers in England who have been able to prove in a study with the help of blood tests that they are not counterfeits and that the medication really gets into the blood. We can discuss these studies with clients, but of course we cannot guarantee the medicines ordered on the Internet. The clinical chemistry department at the USZ has also recently started offering such a blood test. However, this must be paid for privately.

How risky is the PrEP drug?

There were few side effects in the studies carried out, but this was also because the participants were monitored by a doctor every three months and it was therefore possible to react quickly. The main risk with PrEP is kidney damage, especially if other medication is also being taken or if there is previously undetected kidney damage. Osteoporosis can also occur in the long term. Fortunately, these side effects are rare, but do not cause any symptoms in the early stages and can therefore be overlooked. Other side effects are even rarer, but this means that the doctor prescribing PrEP should know the drug well. In addition to classic side effects, there is also a risk with PrEP if you take the medication and are already infected with HIV. This can lead to the development of viral resistance, as the drug is not a complete HIV therapy. This would mean that the patient would have to take a lot more medication to treat their HIV infection. This must be prevented above all because of the associated side effects. It must also be ensured that the patient does not have a chronic hepatitis B infection, as this can lead to serious complications if PrEP is discontinued.

Is that why you recommend controlled intake?

Yes, either in our special consultation hours at the USZ or with another doctor experienced in PrEP. If you go for a check-up every three months, you can react if side effects occur. These are then usually reversible.

What does such a consultation look like?

You can make an appointment via our reception or at prep_infektiologie@usz.ch. We also have time on Thursday evenings to offer appointments outside of working hours. When you register by telephone, we can clarify many questions over the phone. However, most people are already very well informed. As a rule, such an initial consultation takes around 45 minutes, depending on the patient’s level of knowledge. The risks and side effects are discussed, as well as the various options for taking the medication. Some take it permanently in order to be protected every day, others only ever take it, for example. on weekends when unprotected sexual intercourse is planned. However, there is less study data on this type of intake and in my experience it doesn’t work very well for spontaneous dates. In addition to the necessary laboratory tests, we also look for other sexually transmitted diseases and discuss vaccination status.

How well does PrEP protect?

The effectiveness depends heavily on taking the medication correctly. If these are taken daily, the protection is probably at least comparable to condoms. The effectiveness is reduced if the medication is only taken irregularly. But a condom must also be used correctly in order to be effective. Individual cases are known worldwide in which HIV infection occurred despite correct use of PrEP. The same applies to condoms. Unfortunately, there is never one hundred percent in medicine.

Who should take PrEP?

PrEP is one more effective building block we have to protect against HIV. The existing options, above all condoms, remain as relevant as ever. PrEP is aimed at people who have problems using condoms consistently and at the same time have an increased risk of HIV infection. Statistically speaking, this primarily affects homosexual and bisexual men with changing sexual partners in Switzerland. Previous safer sex strategies have not been able to reach all people. This can have various causes, such as a latex allergy or sex under the influence of alcohol or drugs. Statistically speaking, being in love is also such a risk. As a rule, this is not a lifelong intake, but protection for a specific phase of life in which you are particularly at risk. In my experience, no one would voluntarily take a drug if they saw an easier way to have a satisfying sex life. There is also room to talk during the consultation. Some people decide against PrEP after the consultation and stick with condoms. For other risk situations, e.g. In the healthcare sector, there is still the option of post-exposure prophylaxis by taking HIV medication immediately after a possible exposure.

Is the demand for PrEP increasing in Switzerland?

Yes, definitely. However, many do not dare to talk about it for fear of being morally condemned. I hear a lot of really bad experiences in the consultation. In the worst-case scenario, this could lead to someone taking PrEP without a doctor’s supervision. We doctors and health experts need to ask ourselves whether there is anything we can do to improve ourselves.