Tops and Bottoms Prefer Different Forms of Taking PrEP, Study Finds

"Everyone's sex life is different, so we should have different options for preventing HIV."

When gay men think of PrEP (pre-exposure prophylaxis), we think Truvada. In fact, the two have become somewhat interchangeable to HIV-negative men. That’s because the only current FDA approved form of PrEP is taking the Truvada pill daily.

While Truvada has been hailed as miracle drug, decreasing the likelihood of acquiring HIV by 99% for those who adhere to its daily regimen, there are still numerous factors that inhibit gay and bisexual men from using PrEP: issues with insurance, forgetting to take the pill, stigma, and for some, not even knowing that Truvada is an option.

Getty

That’s why researchers have been looking at other safe ways to take PrEP that are equally as effective as Truvada, but don’t require taking a pill daily.

There are two other forms of taking PrEP that are currently in trial: long-acting injections to deliver antiretroviral (i.e., getting a shot once every 8–12 weeks) and topical microbicides (a cream you can either put in your anus or on your penis). There’s also a different regimen for taking PrEP called event-driven PrEP, where instead of Truvada daily, you take it surrounding the dates you know or believe that you’ll be having sex.

Event-driven PrEP was deemed safe in France since 2015, but the World Health Organization hasn’t changed its 2015 recommendation that PrEP should be taken daily, although they do acknowledge that people may stop and restart PrEP according to “seasons of risk.”

PhD student William Goedel and a team of researchers at New York University and University of Chicago surveyed 482 HIV-negative MSM (men who have sex with men) to see which type of PrEP they would be more inclined to use: daily PrEP, event-driven PrEP, long-acting injections, or topical microbicides. Nearly half of respondents reported having condomless anal sex (CAS) in the past three months.

The results of their study, “Are Anal Sex Roles Associated with Preferences for Pre-Exposure Prophylaxis Administration Modalities Among Men Who Have Sex With Men?”, was published in the October issue of the Archives of Sexual Behavior.

Uwe Krejci/Getty

Considering all the HIV prevention options presented, about one-third (31.7%) preferred whichever was most effective. After that, the most commonly preferred HIV prevention method was a long-acting injection (21.8%), followed by event-driven pills (11.0%). Only 8.3% perfect expressed a preference for penile microbicide and 6.6% for rectal microbicide. A once-a-day pill was the least preferred strategy, with a mere 4.8% percent expressing a preference for daily PrEP over other prevention strategies.

The researchers also broke the men down into three groups (tops, bottoms, and versatile) and looked to see how their preferred method for taking alternative forms of PrEP differed by sex role.

Tops were more likely to prefer a penile microbicide (19.6% of tops compared to 4.6% of bottoms/vers). Bottoms were more likely to prefer a long-acting injection (32.9% of bottoms vs. 15.4% of verse/tops).

Regardless of preferences, these new methods of taking PrEP are unfortunately not likely to come out on the market anytime soon. When NewNowNext spoke with Mr. Goedel and inquired about an estimated timeline, he said the furthest along these potential new prevention methods is long-acting injectable PrEP using the drug cabotegravir.

A study testing the efficacy of injectable PrEP started in December of 2016 and is slated to end September 2021. The study (HPTN 083) has the tagline “Give PrEP a Shot” and is an ambitious undertaking, involving 43 sites in seven countries. Injectable PrEP is also being tested among cisgender women in Africa. That trial started in May of 2017 and goes until May 2022.

“Some simulation modeling work I’ve been involved with recently has suggested that if long-acting injectable PrEP works as well in humans as it did in studies in monkeys, it will be more effective than pill-based PrEP,” Goedel explained.

Assuming that’s the case, “We’ll see FDA approval by 2025.”

Topical prevention is even further along than the long-acting injectable. While a recent trial showed a specific rectal microbicide was safe to use among MSM, the Microbicide Trials Network are doing further studies to figure out what the best method to administer this gel (as a douche, a fast-dissolving rectal tablet, or a rectal suppository) before they move onto a larger trial to see if a microbicide can be as effective as pill-based PrEP.

“A penile microbicide was almost completely hypothetical,” Goedel clarified. “I’m unaware of any studies that have evaluated a penile gel. Hypothetically speaking, a topical gel applied to the penis would protect the epithelial tissue of the penis from HIV acquisition.”

“The biggest take away from this study,” Goedel continued, “is that we should be working hard to expand our HIV prevention toolkit. For some people, taking a pill every day is their preference and what makes them feel most empowered in managing their risk of HIV, but some people might not want to take a pill every day.”

He concluded: “Everyone has a right to have the kind of sex that’s most pleasurable to them without fear of HIV, and it’s our responsibility as a scientific community to develop the tools that allow them to do so. Everyone’s sex life is different, so we should have different options for preventing HIV, too.”

Zachary Zane is a writer and activist whose work focuses on sexuality, culture, and academic research. He has contributed to The Washington Post, Rolling Stone, and The Advocate.
@ZacharyZane