How long does it take PreP to work for Tops?

[Constantine]

As a top, how many days does it take before you have full protection?

[+ FrankR]

28 minutes ago, Quincy_7 said:

As a top, how many days does it take before you have full protection?

Take a look here: 

https://heymistr.com/2024/08/08/how-long-for-prep-to-work-a-comprehensive-timeline/?gad_source=1&gbraid=0AAAAAC0g6bbDURytvze5Py8M4DVvDj1p6&gclid=CjwKCAiA3ZC6BhBaEiwAeqfvyvejmZr7HIM1T1MNy1dCwP7kOLd_ogCufHIYuAbtRsHzpL8YcUPbcxoCrY8QAvD_BwE

 

In short: depends on the drug you are taking, if you are taking it as prescribed; but as a rule you get maximum protection after 3 weeks of use for the daily pill. 

Edited November 25, 2024 by FrankR

[Constantine]

1 hour ago, FrankR said:

Take a look here: 

https://heymistr.com/2024/08/08/how-long-for-prep-to-work-a-comprehensive-timeline/?gad_source=1&gbraid=0AAAAAC0g6bbDURytvze5Py8M4DVvDj1p6&gclid=CjwKCAiA3ZC6BhBaEiwAeqfvyvejmZr7HIM1T1MNy1dCwP7kOLd_ogCufHIYuAbtRsHzpL8YcUPbcxoCrY8QAvD_BwE

 

In short: depends on the drug you are taking, if you are taking it as prescribed; but as a rule you get maximum protection after 3 weeks of use for the daily pill. 

Thank you.

[SirBillybob]

The answer is in two parts as I assume a “top” wonders about the confluence of drug concentrations in his bloodstream and mucosal tissue, while not typically exposed to semen, unless of course residual infected semen in the “bottom’s” rectum from very recent encounters which is rare .

Two factors: Insertive anal and time to PrEP protection.

The time to protection in terms of drug concentrations in penile mucosal tissue is not as clear as for rectal mucosal tissue but it is reasonable to assume similar or more tentative. The point is that urethral, glans and foreskin tissue is vulnerable to infection from virus contained in rectal mucosal tissue fluids and traces of rectal blood plasma possibly present, but transmission risk is less than for receptive intercourse. However, bacterial STI infection could increase risk as well.

If a “top” trades off some degree of wait time to peak drug concentration levels, the point at which the advantage of lower behavioural transmission risk by virtue of insertive position is lost is unknown. 

Edited November 25, 2024 by SirBillybob

[Constantine]

2 hours ago, SirBillybob said:

The answer is in two parts as I assume a “top” wonders about the confluence of drug concentrations in his bloodstream and mucosal tissue, while not typically exposed to semen, unless of course residual infected semen in the “bottom’s” rectum from very recent encounters which is rare .

Two factors: Insertive anal and time to PrEP protection.

The time to protection in terms of drug concentrations in penile mucosal tissue is not as clear as for rectal mucosal tissue but it is reasonable to assume similar or more tentative. The point is that urethral, glans and foreskin tissue is vulnerable to infection from virus contained in rectal mucosal tissue fluids and traces of rectal blood plasma possibly present, but transmission risk is less than for receptive intercourse. However, bacterial STI infection could increase risk as well.

If a “top” trades off some degree of wait time to peak drug concentration levels, the point at which the advantage of lower behavioural transmission risk by virtue of insertive position is lost is unknown. 

Could you elaborate on the bolded bit? Sorry but I'm not following.

[SirBillybob]

2 hours ago, Quincy_7 said:

Could you elaborate on the bolded bit? Sorry but I'm not following.

One can approximate the relative risk for bottoms as about 12 times that of tops for one episode of intercourse, outside of PrEP considerations. There is no known relative risk factor for intercourse “too soon” following initial PrEP dosing because that time frame is continuous whereas sexual position is binary. The increase in risk is theoretical.

However, the top engaging in intercourse “too soon” forfeits some of the aforementioned risk difference relative to the bottom who delays intercourse until optimal drug levels are obtained. Since penile mucosal tissue drug concentrations may be similar to vaginal concentrations in that it is known such vaginal concentrations are much less and take longer to accrue compared to rectal mucosal tissue (either gender), practice wisdom would not lean towards tops shortchanging the duration of time in which intercourse postponement is recommended.

Edited November 25, 2024 by SirBillybob

[+ Notor]

37 minutes ago, SirBillybob said:

One can approximate the relative risk for bottoms as about 12 times that of tops for one episode of intercourse. There is no known relative risk factor for intercourse “too soon” following initial PrEP dosing because that time frame is continuous whereas sexual position is binary. The increase in risk is theoretical. However, the top engaging in intercourse “too soon” loses some of the aforementioned risk difference relative to the bottom that, say, delays intercourse until optimal drug levels are obtained. 

What does all of this mean if you are using Prep on the 2-1-1 dosing?

[SirBillybob]

1 hour ago, Notor said:

What does all of this mean if you are using Prep on the 2-1-1 dosing?

It’s a good question because obviously a one-week lead-in does not occur. Since there is very little difference in drug concentrations and no difference in estimated protection between an average number of 4 doses vs 7 doses weekly, as well as no difference in breakthrough infection comparing 2-1-1 and daily, it is assumed that the 2-dose on-demand lead-in augmentation of drug concentration is sufficient for equivalent protection. Drug concentrations are in fact specifically organized around the risk event. However, the actual breakthrough infection risk cannot be compared for single events within the two uptake versions because a study can only compare by person-time denominators and number of intercourse risk events is impossible to comparatively tally over time. Similarity in breakthrough infection incidence may be a function of greater protection conferred by daily dosing that is undermined by a greater frequency of risk events.

Therefore, the preference is based on convenience and the frequency and capacity to forecast events, or to be able to access some degree of protection for an impromptu encounter. 

That said, full protection is a misnomer. Protection can only be as good as it gets. 

Edited November 26, 2024 by SirBillybob

[+ ApexNomad]

Speak with your doctor or your a healthcare provider about your specific needs and concerns regarding PrEP. They can provide personalized advice, answer all your questions, and ensure you’re using the medication correctly. While forums can be helpful for shared experiences, they are no substitute for professional medical guidance.

[marylander1940]

2 hours ago, ApexNomad said:

Speak with your doctor or your a healthcare provider about your specific needs and concerns regarding PrEP. They can provide personalized advice, answer all your questions, and ensure you’re using the medication correctly. While forums can be helpful for shared experiences, they are no substitute for professional medical guidance.

[+ PhileasFogg]

I agree with consulting medical professionals.   My research indicated 7 days was sufficient.   Keeping also in mind that the risk as a top WITH an + partner is 0.11%.   Of course, having been around in the 80's, I will admit that the odds of transmission in the table I've linked seem low.

 

[Luv2play]

On 11/29/2024 at 11:07 AM, PhileasFogg said:

I agree with consulting medical professionals.   My research indicated 7 days was sufficient.   Keeping also in mind that the risk as a top WITH an + partner is 0.11%.   Of course, having been around in the 80's, I will admit that the odds of transmission in the table I've linked seem low.

 

In the risk figure of 0.11percent you cite, does that apply to pos partners who have undetectable status or those who have a detectable viral load?

[+ PhileasFogg]

39 minutes ago, Luv2play said:

In the risk figure of 0.11percent you cite, does that apply to pos partners who have undetectable status or those who have a detectable viral load?

If I’m reading the table in the link correctly, zero%

[SirBillybob]

19 hours ago, Luv2play said:

In the risk figure of 0.11percent you cite, does that apply to pos partners who have undetectable status or those who have a detectable viral load?

The distinction isn’t made because the synthesized estimate is based on a combination of incidence rates according to estimates of background prevalence, essentially receptive partner HIV positive or serostatus unknown, and of incidence rates based on partner HIV positive, obviously viral load data unavailable overall. 

Since being “top” uncircumcised insertive partner is much higher risk it is odd that the final estimate of .11% did not seem to incorporate that metric. However the authors point out a UIAI risk estimate of .22% in another study, not stratified according to circumcision.

Interestingly, a “top” anally is more likely to be infected from a positive partner than a woman’s likelihood of acquiring infection from vaginal intercourse with a positive male partner. It can be as much about circulating virus in mucosal secretions as virus in semen. 

Edited December 4, 2024 by SirBillybob

[Twinkslover]

On 11/25/2024 at 12:10 PM, Quincy_7 said:

As a top, how many days does it take before you have full protection?

As per my doctor , you need to take continuous 7 days to make it  effective and continue  forever then. 

[SirBillybob]

3 hours ago, Twinkslover said:

As per my doctor , you need to take continuous 7 days to make it  effective and continue  forever then. 

Not how my doctor, correctly as per guidelines, prescribes Truvada (& it’s generic formulation) in all cases, as less frequent time-planned risk activity will dictate a tailored uptake, and transitioning from on-demand to daily, however temporary or sustained, will consider the drug concentration loading conferred by the initial double dose, reducing the absolute 7-day imperative.

I’m sexually active, forever, and we settled on not taking PrEP daily, though I may at times follow the one-week dose loading as anticipatory substitute for 2-dose lead in for more immediate activity. In which case I have aligned with the daily PrEP option but never “forever”, just a few days following the final sexual activity that truncates daily PrEP. I and others fall within sexual activity scenarios that counter the notion of what daily PrEP in reductionist terms means. The uptake two-model binary is artificial. 

As my doctor puts it, one size does not fit all. My doctor takes the time to evaluate my risk factors, sexual activity patterns, adherence capability (given that on-demand poses unique requirements), and integrate renal health considerations, reminding me also that supplementation with condom use is the ideal overall prophylaxis. 

The topic question did not distinguish among uptake protocols or oral PrEP medications chosen. But yes, the recommended 7-day lead-in applies to either Truvada or Descovy where sex can be deferred for a week. Descovy is not applicable for on-demand PrEP.

If you absolutely cannot defer risk activity, say, on Day 3 of lead-in dosing where you can postpone a spontaneous activity offer for minimally 2 hours and your doctor never clarified that you should transition to on-demand with an added dose at that juncture you were shortchanged valuable information. Unfortunately, die-hard thumbs-downers regarding the on-demand option have led some to conflate an impromptu transition to on-demand as running afoul of clinical recommendations. Have that extra pill accessible for drug concentration enhancement. In such a case my doctor adds that it makes sense to load the additional dose if it’s Descovy, notwithstanding that only Truvada is prescribed for the on-demand protocol. The reality is that some folks commence PrEP based on anticipated opportune sexual activity with pressing immediacy.

Edited June 7 by SirBillybob

[Twinkslover]

Frankly I forge to take pills. I am also not sexually very active.  i am thinking to  take injection shot as my doctor said it is  once in 2 months.

[SirBillybob]

29 minutes ago, Twinkslover said:

Frankly I forge to take pills. I am also not sexually very active.  i am thinking to  take injection shot as my doctor said it is  once in 2 months.

You can decide together. But for me, infrequent sexual activity would be the determining factor that would predispose me to on-demand pills as it could be as simple as remembering 3 times across 3 consecutive days a few times yearly as opposed to 6 injections spaced apart in a rigid time frame, or optionally a few one-week dose loading iterations annually, scheduled by smartphone alarm reminder. 6 scheduled shots added to routine HIV and STI testing annually, being financial stable with no work obligations, would really cramp my travel planning. However, I am more than happy to forego risky sex in favour of satisfying intimacy, without feeling deprived and frustrated, but that does not call for prophylaxis if an offer presents itself that cannot be turned down.

Edited June 7 by SirBillybob

[Twinkslover]

ok.

[Twinkslover]

My insurance covers though. 

[SirBillybob]

26 minutes ago, Twinkslover said:

My insurance covers though. 

Sure, whatever arrangement is within reach based on cost coverage and ensuring you have prophylaxis on board that fits your activity. My point refers to balancing the choice with when one actually needs infection protection, to the extent that one can predict those time frames. What are the diminishing returns? I would prefer to pay $1,500 annually for on-demand Truvada than receive injected Cabotegravir 6 times for free. But then with Cabotegravir I would also reduce or eliminate transmission risk during each 2-week tail phase within each 2-month block and also consider that it’s use may delay diagnosis of breakthrough HIV infection within a regularized testing regimen. No one option eliminates planning inconveniences. 

Edited June 7 by SirBillybob

[Constantine]

22 hours ago, Twinkslover said:

Frankly I forge to take pills. 

 

On a related note, this is my issue with U=U. It only works if the person is taking their pills daily. That's the quiet part that people leave out.

[SirBillybob]

54 minutes ago, Quincy_7 said:

 

On a related note, this is my issue with U=U. It only works if the person is taking their pills daily. That's the quiet part that people leave out.

That and Quiet 2: Even if adherent a re-infection will likely elevate viral load to above the undetectable threshold if not above the virally suppressed threshold. You may be essentially having sex with one or more previous D=T partners and he won’t necessarily know his TasP and U=U are subverted with an up-blip in viral load, maybe even transient superinfection, in spite of having been taking meds properly. A condom in my wreckedom if you please. 

Edited June 8 by SirBillybob

[+ BenjaminNicholas]

1 hour ago, Quincy_7 said:

 

On a related note, this is my issue with U=U. It only works if the person is taking their pills daily. That's the quiet part that people leave out.

And that's why PrEP exists.  You protect yourself.  

U = U is fine for those who are positive and know they take their meds.

[pubic_assistance]

On 11/25/2024 at 12:10 PM, Quincy_7 said:

As a top, how many days does it take before you have full protection?

I am confused by this question.

WHY would efficacy be different for a top than a bottom ? 🤔

I 'get' that the bottom is taking a BIG load of virus, while the top is somewhat less likely to have virus sneak in, but it only takes ONE little virus to start an HIV infection ....so to me whether top or bottom, you need the same protection.