Escorts on PreP

[jcmiami1]

i will be in NYC next week for a couple days. I saw an escort on RB in Manhattan. He's definitely "my type" - on his ad he reports he's on PreP no problem I have no problem with that and he reports he also goes for regular STD screenings. Now no where on his ad does he indicates "always safe" sex. I know a few guys on PreP and they admit to barebacking. I'm planning to ask directly - any thoughts on this?

[Steven_Draker]

I think you have already the answer to your question, JC

 

If the "safe sex" question is not answered, it's for a reason.

[jcmiami1]

Actually I just texted him with that question let's wait and see lol

[jcmiami1]

I scratched him off the list completely...he has not responded but my "big" head kicked in - it's a "no go" ... I guess I needed just a push lol

[corndog]

Although I'm still skeptical about the long term viability of PreP, I think it makes sense for escorts, as part of their personal safety regimen. So, I don't knock escorts for going on PreP, but as far as I understand it, all of the health care professionals who advocate use of PreP, recommend that it be used in addition to condoms to provide a higher level of protection. I think that a lot of people are making the decision to use PreP instead of other safer sex practices, and I don't think they have the research backing them up.

 

In this situation, I'd ask the escort to use a condom with me, and as long as he agrees, I'd probably go through with the appointment. I've often bristled at suggestions that what someone does on their own time is their own business. When it comes to safer sex, I don't really buy that. However, my real issue with barebackers has been that they show disregard for their own health and the health of their clients, and I wouldn't trust them to conscientiously use a condom. In the case of an escort who is on PreP, but willing to bareback, I believe that they're misguided, but I don't harbor that element of distrust. If they're being honest in all other respects, I can disagree with their personal decision, but I can respect their intention to be safe, and I would trust them to use a condom if they agreed to it.

 

I think that most would agree that we'd never trust when someone says "I'm HIV Negative." It's an inherently untrustworthy statement. Moving forward, we need to be equally skeptical of people who claim to be on PreP. We can't know if they really are, or if their adherence to the regimen is strict enough to be effective. I would never forgo a condom because someone claims to be HIV Negative, and I don't plan to ever forgo a condom because someone claims to be on PreP.

[+ stevenkesslar]

I know a few guys on PreP and they admit to barebacking. I'm planning to ask directly - any thoughts on this?

 

Since you got your original question asked, can we use this thread to talk about the COST and effectiveness of PreP?

 

On the thread on barebacking, Steven Draker posted a link that said the following:

 

Without insurance, Truvada can cost up to $14,000 a year, according to the CDC. But for most people, it is covered in their insurance programs and there's only a co-pay. There are also medication assistance programs across the US for the uninsured that will cover the entire cost of the medication.

 

The same thread said this:

Participants who took the drug less than half the time had a 50 percent reduction in HIV acquisition; daily users cut their risk by more than 90 percent. These results have been supported by other studies in a range of populations — from injection-drug users to heterosexual men and women. The trouble is, most people don't take their medications as their doctors prescribe.

http://www.vox.com/2014/7/14/5896887/explainer-about-the-pill-to-prevent-hiv-aids-Truvada

 

Bottom line is that the drug, which I don't take, sounds like it has potentially huge prevention efficacy, but only if you can spend $14,000 a year on it or have insurance that covers it.

 

I've asked a number of escorts about this, and so far the conversations I've had have created as more confusion as clarity.

 

For example, I've heard this idea that the gay-for-pay "white twenty somethings" who bareback like rabbits on porn websites like Sean Cody are on PreP, which is why they can safely bareback. I think that sounds like total BS. I doubt straight guys who are looking to make a little bit of extra money by fucking other straight guys are taking PreP. More likely, I believe they are probably safe simply because they fuck other guys rarely, and only for pay.

 

When it comes to gay escorts, like me, I've heard the idea that you can get the drug "for free," like if you have a client that is a doctor. I highly doubt that either. A few times doctor clients have given me samples of things like Viagra or Cialis. I doubt most doctors are getting enough free samples to give away one year "free" prescriptions of a $14,000 a year drug.

 

I do plan to ask my doctor (at Kaiser) whether regular insurance covers this. Maybe it's just my own ignorance, buy somehow I find it hard to believe all the big bad insurance companies are dishing out $14,000 a year for pills that can be viewed as a substitute for condoms, which are much cheaper.

 

So the first question is, does anyone know what the practical economics of being on PreP (Truvada) are? It seems like it has to be really expensive. Do most insurance companies really cover it?

 

Also, while we are at it, and at the risk of confusing things with my long-windedness, read this from a report on undetectable viral load:

 

The second large study to look at whether people with HIV become non-infectious if they are on antiretroviral therapy (ART) has found no cases where someone with a viral load under 200 copies/ml transmitted HIV, either by anal or vaginal sex. Statistical analysis shows that the maximum likely chance of transmission via anal sex from someone on successful HIV treatment was 1% a year for any anal sex and 4% for anal sex with ejaculation where the HIV-negative partner was receptive; but the true likelihood is probably much nearer to zero than this.

http://www.aidsmap.com/No-one-with-an-undetectable-viral-load-gay-or-heterosexual-transmits-HIV-in-first-two-years-of-PARTNER-study/page/2832748/

 

In one of the videos on the barebacking thread, someone stated "Everybody has the right to sex without fear." Yes, and everybody also has the right to be a drop dead gorgeous millionaire, except on the planet I live on. Fear is good, and in my view there are three directions fear can take you:

 

1. Use condoms

2. To prevent HIV, take Truvada

3. If you have HIV, seek treatment and have an undetectable viral load.

 

What's interesting to me is that of #2 and #3, the statistics suggests that if the goal is to stop the spread of HIV, #3 is actually more effective. In other words, the chance of getting HIV from somebody who is poz and undetectable is stated to be 4 %, at worst, whereas the chance of getting HIV if you are on Truvada is stated to be 10 %, at best, assuming you bareback and you are spending $14,000 a year or your insurance covers it and you are taking a pill a day.

 

The three choices above are not either/or, but I'm curious what other people make of this. My second question: how would you rank the relative efficacy of HIV prevention given the three choices above? (The fourth choice, of course, is celibacy. Count me out on that).

[thickornotatall]

i will be in NYC next week for a couple days. I saw an escort on RB in Manhattan. He's definitely "my type" - on his ad he reports he's on PreP no problem I have no problem with that and he reports he also goes for regular STD screenings. Now no where on his ad does he indicates "always safe" sex. I know a few guys on PreP and they admit to barebacking. I'm planning to ask directly - any thoughts on this?

I always assume that everyone lies about their status...keeps me safe...why would you believe someone you don't know..?....Protection all the time...every time...no BB....no swallowing...no open sores in the mouth.....seeing friends die has been painful...I know better...and know how to protect myself...

[doitb4ugo]

As an openly HIV+ man, I find all the discussions about PreP to be interesting and always confusing.

1. If you are having sex with a man is it preferable that he not be on PreP?
   
2. If you are having safer sex and using condoms, are you really safe from getting HIV. If yes, what difference does his drug regiman make to the transaction?
   
3. If you think you are only having sex with Hiv- men, how can you know. And if you can't really know, Is safer sex your solution.
   
4. I am out in the world having sex. Can any of you feel safe knowing that.
   

Attitudes about HIV+ men will continue long after the science has spoken. If HIV is ever cured, will men who had it ever be able to forget having it.

[sincitymix]

I do plan to ask my doctor (at Kaiser) whether regular insurance covers this. Maybe it's just my own ignorance, buy somehow I find it hard to believe all the big bad insurance companies are dishing out $14,000 a year for pills that can be viewed as a substitute for condoms, which are much cheaper.

 

Working in the pharmaceutical insurance business for 13+ years, I can most definitely say, it really depends on the insurance.

Usually with most insurances If the MD says its for pre exposure prophylaxis treatment, it will get a big fat denied.

However, most insurances don't usually ask for proof, prior authorization, and other coverage criteria. (generally under the assumption that if the MD is prescribing it, you must have HIV and don't have the time to muck around with Pa's), hence some MD are able to get around the said pre exposure prophylaxis denial by not mentioning its for prep.

Then there are the really high end insurances that charge an arm and a leg, that covers everything.

and just hope you aren't on the barebones cheap insurance that requires a pa or managed care coverage for every medication under the sun with proof of need.

[rguer]

I do plan to ask my doctor (at Kaiser) whether regular insurance covers this. Maybe it's just my own ignorance, buy somehow I find it hard to believe all the big bad insurance companies are dishing out $14,000 a year for pills that can be viewed as a substitute for condoms, which are much cheaper.

 

I did a Google search on "does kaiser pay for truvada" and the contradictory answers are:

 

- It is on the Kaiser formulary; there's a special program you might be referred to (for additional education and testing).

- Some plans might not include Truvada in their custom formulary.

- Some doctors are better informed than others, so hope you have an informed one.

 

http://www.healthline.com/health-news/hiv-truvada-qa-michael-rubio-020714#2

Were you concerned about how much the drug would cost?

Rubio: Cost wasn’t a concern. I’m fortunate—it was really easy for me to access. I have Kaiser. I contacted my doctor via email and told her I was interested and wanted to know what steps I needed to take, and she basically sent my information to another department within Kaiser, and they contacted me and set up an appointment to screen me to see if I was an appropriate candidate for PrEP.

 

I had to do extensive testing to make sure I was not positive and to make sure my kidneys and liver were functioning properly, because of the damaging effects if they are not already healthy. Most insurance companies will cover it, and even if you don’t have insurance, there are other avenues you can take. I was really fortunate: I just had to email my doctor and wait a few weeks for an appointment. I do have to pay copay for labs and the medicine.

 

http://www.sfgate.com/health/article/Health-providers-slowly-embrace-drug-Truvada-to-5526316.php

Kaiser San Francisco has built up a program to make it easier for uninfected members to see an expert and get a Truvada prescription.

[...]

"Our approach at Kaiser is PrEP is a very responsible way to address your sexual health," said Dr. Brad Hare, former head of Ward 86 who is now director of HIV care and prevention at Kaiser San Francisco. "But it is a serious intervention. These are expensive drugs that need to be used responsibly."

[+ stevenkesslar]

I did a Google search on "does kaiser pay for truvada" and the contradictory answers are:

 

Thanks! Interesting stuff. Maybe, maybe not.

[rvwnsd]

Working in the pharmaceutical insurance business for 13+ years, I can most definitely say, it really depends on the insurance.

Usually with most insurances If the MD says its for pre exposure prophylaxis treatment, it will get a big fat denied....

 

Although I did not pursue a prescription, Truvada as PrEP was covered under my United Healthcare HMO with a prior authorization. Under my current Anthem HSA plan, I would pay $650 for a 30-day retail supply and $1,200 for a 90-day mail order supply.

 

Thanks! Interesting stuff. Maybe, maybe not.

 

Gilead, the maker of Truvada, has an assistance program that covers a substantial portion of the cost. The assistance program applies to most retail pharmacies, but I can't say whether Kaiser's pharmacy would be covered.

[sincitymix]

Although I did not pursue a prescription, Truvada as PrEP was covered under my United Healthcare HMO with a prior authorization. Under my current Anthem HSA plan, I would pay $650 for a 30-day retail supply and $1,200 for a 90-day mail order supply.

 

Covered with Prior authorization means the MD has to provide proof of medical necessity before its covered. Insurances don't usually count PrEP as a criteria to prove medical necessity.

 

Is that cost for the HSA plan before or after the deductible? At least your getting a negotiated discounted rate with the medication prices.

[sincitymix]

I did a Google search on "does kaiser pay for truvada" and the contradictory answers are:

 

- It is on the Kaiser formulary; there's a special program you might be referred to (for additional education and testing).

- Some plans might not include Truvada in their custom formulary.

- Some doctors are better informed than others, so hope you have an informed one.

 

http://www.healthline.com/health-news/hiv-truvada-qa-michael-rubio-020714#2

Were you concerned about how much the drug would cost?

Rubio: Cost wasn’t a concern. I’m fortunate—it was really easy for me to access. I have Kaiser. I contacted my doctor via email and told her I was interested and wanted to know what steps I needed to take, and she basically sent my information to another department within Kaiser, and they contacted me and set up an appointment to screen me to see if I was an appropriate candidate for PrEP.

 

I had to do extensive testing to make sure I was not positive and to make sure my kidneys and liver were functioning properly, because of the damaging effects if they are not already healthy. Most insurance companies will cover it, and even if you don’t have insurance, there are other avenues you can take. I was really fortunate: I just had to email my doctor and wait a few weeks for an appointment. I do have to pay copay for labs and the medicine.

 

http://www.sfgate.com/health/article/Health-providers-slowly-embrace-drug-Truvada-to-5526316.php

Kaiser San Francisco has built up a program to make it easier for uninfected members to see an expert and get a Truvada prescription.

[...]

"Our approach at Kaiser is PrEP is a very responsible way to address your sexual health," said Dr. Brad Hare, former head of Ward 86 who is now director of HIV care and prevention at Kaiser San Francisco. "But it is a serious intervention. These are expensive drugs that need to be used responsibly."

 

That's one of the good things about Kaiser, they are considered a Golden Standard. Not many insurances follow suit though. Its usually the insurance who says we wont cover xxx yyy.. and/or the client (the employer) usually says we agree, make the insurance plan for us to save us the most money.. or the client says you cover xxx yyy, we don't want to cover xxx yyy.. insurance benefit manager, Yes sir! we will not cover xxx yyy at your instructions!

[bobnyc]

I do plan to ask my doctor (at Kaiser) whether regular insurance covers this. Maybe it's just my own ignorance, buy somehow I find it hard to believe all the big bad insurance companies are dishing out $14,000 a year for pills that can be viewed as a substitute for condoms, which are much cheaper.

 

Kaiser covers it for me. The big thing about PrEP is that you have to be negative to start it or you can possibly breed a resistant form of HIV to PrEP in which case it becomes useless for those taking it for prevention purposes. There's a lot of testing prior and testing on it. They have a protocol that they use and they still advocate condom use since that was what was used in the often quoted study. They're quite nice about it and after going through all of it ultimately leave the decision to you. The only thing that will automatically disqualify you is if you have HIV. They will test for HIV RNA viral load at the first visit to try and make sure that you do not have it even. They really do due diligence.

[rvwnsd]

Covered with Prior authorization means the MD has to provide proof of medical necessity before its covered. Insurances don't usually count PrEP as a criteria to prove medical necessity.

 

I worked for a PBM several years ago and the standard for "medical necessity" varies. As I stated, UnitedHealthcare would pay for Truvada as PrEP. The information sheet contained the conditions required in order for it to be covered, including bloodwork (not just an HIV test showing the patient is negative, but tests to baseline liver and kidney functionality, etc), physician monitoring, and follow-up bloodwork at regular intervals. Based on the explanation in the info sheet, the prior authorization was required to ensure the physician and patient were complying with the protocols required when administering PrEP.

 

Is that cost for the HSA plan before or after the deductible? At least your getting a negotiated discounted rate with the medication prices.

 

That is my share of the cost before my deductible, which I am close to meeting. The plan covers approximately 51% of the cost and I pay the rest. As I mentioned in my post, Gilead has an assistance program which covers most of the cost.

[+ DickyF]

I'm not in the medical field but I know a couple of health workers at the big gay clinic in DC and they say the following:

Those taking PrEP just to have BB sex rather than use condoms and have safer sex are putting a significant financial burden on the healthcare system (unless they are paying for the drugs out of their own pocket).

I think it's nutty and irresponsible.

[+ stevenkesslar]

I'm not in the medical field but I know a couple of health workers at the big gay clinic in DC and they say the following:

Those taking PrEP just to have BB sex rather than use condoms and have safer sex are putting a significant financial burden on the healthcare system (unless they are paying for the drugs out of their own pocket).

I think it's nutty and irresponsible.

 

Now that I'm learning about it this is the conclusion I'm headed toward, I think.

 

What the numbers in the studies I cited above suggest is that you are better off having safer sex (with condoms) with guys who are poz and undetectable than you are barebacking and using PreP. Am I doing the math wrong? The study above said the chance of getting HIV from somebody poz and undetectable is 4 % versus a 10 % chance of getting HIV if you use PreP daily (in other words properly) and bareback. I'm assuming using rubbers would move either chance to 0 % (or close to it) and it sounds like that is what is recommended even for people on PreP.

 

It sounds like PreP might be a good option for neg guys in LTRs with poz partners and maybe some other specific circumstances. But if the studies are right really the best thing to get rid of HIV is for poz guys to be on medication and stay undetectable and for everybody else to use rubbers. If everybody used PreP simply to avoid using condoms it sounds like the expense would be huge, and even if its "free" to some with insurance or subsidies there's still possible side effects. This discussion is just reinforcing what I already thought was the KISS principle: always use rubbers.

[rguer]

 

It sounds like PreP might be a good option for neg guys in LTRs with poz partners and maybe some other specific circumstances. But if the studies are right really the best thing to get rid of HIV is for poz guys to be on medication and stay undetectable and for everybody else to use rubbers.

I don't think many people would disagree with that (except for the "else" - I'd go for plain "everybody"). The problem is that it won't happen.

[Frequentflier]

I saw an ad on RB for a guy whose ad stated he only plays safe and is on Prep. I guess he's just being really cautious.

[rguer]

I saw an ad on RB for a guy whose ad stated he only plays safe and is on Prep. I guess he's just being really cautious.

It's what I would do. The condom protects against other STIs and Truvada-resistant HIV, and the Truvada protects against condom breaks and slips and the possibility of infection through a skin break.

[+ stevenkesslar]

It's what I would do. The condom protects against other STIs and Truvada-resistant HIV, and the Truvada protects against condom breaks and slips and the possibility of infection through a skin break.

 

Yes, but it sounds like HIV treatment is just as effective as Truvada in protecting against condom breaks IF treatment results in undetectable viral load. The other thing this makes clear is that the emphasis still needs to be on getting people with HIV diagnosed and treated.

 

If Truvada leads prople to think they can go bareback people who are undiagnosed and/or untreated and have viral loads it could actually lead to infection.

[bobnyc]

Yes, but it sounds like HIV treatment is just as effective as Truvada in protecting against condom breaks IF treatment results in undetectable viral load. The other thing this makes clear is that the emphasis still needs to be on getting people with HIV diagnosed and treated.

 

If Truvada leads prople to think they can go bareback people who are undiagnosed and/or untreated and have viral loads it could actually lead to infection.

 

The big study on PrEP actually told patients to use condoms in addition to the medication. It's pretty much never mentioned but it was at my Kaiser counseling on PrEP.

 

The big thing about undetectable is that there will be spurts where the virus is detectable in the system that we don't know of. It's not like the person is always undetectable if their one blood test says undetectable, they're only undetectable at that time. There will be blips and unless that person shows you their bloodwork that says undetectable and it's recent then I wouldn't trust it. Anyone can say that they're undetectable and lie about it too.

[+ stevenkesslar]

Anyone can say that they're undetectable and lie about it too.

 

Exactly.

 

#1. I'd never ask a sex partner to see a viral load test.

 

#2. As you said, even if it was it could be irrelevant.

 

The good news is that the odds of having a rubber break with someone who also happens to have a high viral load is probably extremely low.

[ZhenXBear]

Thanks! Interesting stuff. Maybe, maybe not.

 

I think it's definitely going to depend on your health plan coverage. My pharmacy coverage has a costing application on their website to tell you how much it's going to be for retail and home delivery for any drugs on formulary. I plugged it in and it comes back $25.00/month retail and $50.00 for 90 days.