HIV PrEP for Travel – Things You Need to Know

What is HIV PrEP?

Use of oral anti-retroviral drugs by HIV-uninfected people to block the acquisition of HIV before exposure to HIV.

Why HIV PrEP?

Many trials have been conducted to determine the effectiveness of oral HIV PrEP across couples of all orientations. When patients follow the treatment and prevention strategies closely, significant prevention of HIV levels was achieved
In 2014, WHO (World Health Organisation) developed consolidated HIV guidelines for key populations, including men who have sex with men, sex workers, transgender people. In those guidelines, HIV PrEP was strongly recommended for men who have sex with men (MSM).6
During travel, the risk of acquiring HIV is the result of a change of HIV prevalence at the destination, and more importantly the change of sexual behaviour abroad and the increase of risk-taking behaviour. Studies have shown that amongst the MSM community, awareness of a special form of PrEP use, often described as “holiday PrEP” is becoming increasingly popular. This holds true even for MSM who do not consider themselves to be at high risk for HIV.7

How?

Prior to starting PrEP, your doctor will do blood tests to monitor your kidney and liver function, a full STI screen if you have not had one recently and also an HIV test.
Subsequently when on PrEP, your renal function will be monitored every quarter. Long-term PrEP use will also require monitoring of your bone density.

When?

How you take your PrEP depends on10:

  • how far in advance you plan on having sex
  • how regularly you have sex.

It does not necessarily depend on how much sex you have.

There are 4 Different Ways to Use HIV PrEP

There are 4 different ways to take PrEP, we discuss this further below:

1. Daily PrEP


Daily PrEP Regimen: 

  • Lead in time 7 days.
  • Taken daily at the same time  +/- a few hours ok

Type:

  • Anal, Vaginal/Frontal sex

Considerations:

  • Can be taken any time of the day with or without food
  • In the event a pill is missed, adequate protection is still conferred.

2. On-Demand PrEP (Event-Based Dosing)

On-Demand PrEP Regimen: 
Planned condom-less sex 24 hours in advance:
Strictly:

  • take 2 pills 2 – 24 hours before sex
  • take 1 pill on the day of sex
  • take 1 pill 24 hours later

If having sex for an extended period of time, perhaps over a few days or a weekend, continue to take a pill every 24 hours until you have 2 sex-free days.


The regime requires the patient to take 2 tablets of the HIV PrEP medicine between 2 to 24 hours prior to the event followed by 1 tablet 24 hours after the initial dose and a final tablet 48 hours after the initial dose. Medical studies show that the protection provided against HIV for this regime is not as good as if the medicine is taken daily.
Furthermore, thus the regime is more complex and therefore increases the risk of the patient taking the wrong amount of medicine at the wrong time.

Type: 

  • Only for Anal sex
  • More studies required to show effectiveness in Vaginal/Frontal sex

Considerations:

  • This option is not recommended if you have an active hepatitis B infection. The drugs in PrEP also suppress the hepatitis B virus and so starting and stopping PrEP can cause viral flare-ups and liver inflammation.

3. Ts and Ss (Tues, Thurs, Sat, Sun dosing)


Ts and Ss Regimen:

  • Daily dosing for 7 days,
  • then dropping down to 4 pills per week on Tues/Thurs/Sat/Sun

Type: 

  • Only for Anal sex
  • More studies required to show effectiveness in Vaginal/Frontal sex

Considerations:

  • If you only have sex once or twice a month, you might not want to take a pill every day.
  • 4 pills per week will maintain a good baseline of the drug in your system and you can choose to increase up to daily 7 pills per week when you know you’re in a more sexually active period.
  • Some people using PrEP On Demand find that they might be taking 4 pills per week most weeks of the month and so opt for structuring this into the Ts and Ss instead.

4. Holiday PrEP


Holiday PrEP Regimen:

  • PrEP before a pre-planned block of time when your risk of exposure to HIV will be higher due to:
    • an increased number of partners of unknown HIV status
    • situations where condoms are not easily or always used
    • where alcohol or substances might be used
    • having sex while travelling to a country with a high HIV prevalence
  • Based on a 7-day period we recommend 7-7-7:
    • 7 days daily dosing before the period
    • 7 days daily dosing during the period (or for as long as the specific period lasts)
    • 7 days daily dosing after the period.

Type: 

  • Anal, Vaginal/Frontal sex

Considerations:

  • 7 days of PrEP before and after your last sexual encounter for several reasons:
    • 7 days lead-in provides adequate levels for both anal and vaginal or frontal sex.
    • 7 days lead in before the holiday or travel will allow the body to adjust to any possible side effects, most people do not experience any and these should have subsided within a week.

Worry Less, Worry Free!
PrEP is an ‘opt-in’ treatment – it is not meant to be taken forever.
Trying to stay HIV negative during the holiday or trip result in an anxious and stressful experience.
Your peace of mind and release from this stress and anxiety is important so that you can enjoy the moments that matter with your partner!
Safe Trip and Have Fun!
This article was written by Dr Tan & Partners, in collaboration with Oogachaga.


References

  1. Vivancos R, Abubakar I, Hunter PR. Foreign travel, casual sex, and sexually transmitted infections: systematic review and meta-analysis. International Journal of Infectious Diseases. 2010;14(10):e842–51.
  2. Svensson P.,et al. A meta-analysis and systematic literature review of factors associated with sexual risk-taking during international travel. Travel Medicine and Infectious Disease. 2018; Jul – Aug;24:65-88
  3. https://wwwnc.cdc.gov/travel/page/std
  4. https://www.fitfortravel.nhs.uk/advice/general-travel-health-advice/sexual-health-risks
  5. Riddell Jt, Amico KR, Mayer KH. HIV Preexposure Prophylaxis: A Review. Jama. 2018;319(12):1261-8.
  6. WHO Guidelines Approved by the Guidelines Review Committee. Guideline on When to Start Antiretroviral Therapy and on Pre-Exposure Prophylaxis for HIV. Geneva: World Health Organization Copyright (c) World Health Organization 2015.; 2015.
  7. Elsesser SA, Oldenburg CE, Biello KB, Mimiaga MJ, Safren SA, Egan JE, et al. Seasons of Risk: Anticipated Behavior on Vacation and Interest in Episodic Antiretroviral Pre-exposure Prophylaxis (PrEP) Among a Large National Sample of U.S. Men Who have Sex with Men (MSM). AIDS and behavior. 2016;20(7):1400-7.
  8. Brett-Major DM, Scott PT, Crowell TA, Polyak CS, Modjarrad K, Robb ML, et al. Are you PEPped and PrEPped for travel? Risk mitigation of HIV infection for travelers. Tropical diseases, travel medicine and vaccines. 2016;2:25
  9. Hampel B, Reinacher M, Fehr JS, HIV pre-exposure prophylaxis (PrEP): Is it time to rethink HIV prevention in travelers?, Travel Medicine and Infectious Disease (2018), doi: 10.1016/j.tmaid.2018.06.008
  10. https://www.iwantprepnow.co.uk/how-to-take-prep/

Sexual Health Advice for Traveller

Passport, Phone, Plane tickets and….. PrEP!

Planning your next trip – for business or pleasure, or both? Apart from the usual, do you make plans for your own sexual health?

What? Why?
Whether you’re straight, gay, lesbian, bisexual, transgender or just curious and questioning, lots of people have casual sex when they travel, so you’re not alone.
However, lots of research and experience show that the risk of developing a sexually transmitted infection (STI) – like HIV, syphilis or others – is increased when you travel. 1
This could be due to increased risk-taking behaviour when we travel abroad. The reasons may include increased freedom, alcohol and drug use, loneliness, peer pressure or a general sexual lifestyle when you’re abroad.2
Of course, there are those who travel abroad specifically for sex, in what some call “Sex Tourism”, which is the intention of travel overseas to purchase sex. This usually involves travelling to neighbouring countries to purchase sex from commercial sex workers.
Whatever your reasons for travel, if you’re unprepared for sex you may be putting yourself at risk and participate in behaviours that you wouldn’t consider at home.3
 

So how? Top tips for your Sexual Health Risk Reduction  (T.R.A.V.E.L)

T for Testing & treatment of STIs

  • Please get tested prior to travel as blisters, ulcers, bumps provide an entry point for STIs into the body. Having an STI increases the risk of HIV transmission by 10 fold!
  • Periodic STD Screening & Anonymous HIV Testing can keep your status in check
  • Don’t assume your partner is STD-free because s/he doesn’t mention it and, STDs are often asymptomatic. Talk openly with him or her about your STD and HIV status and date of the last testing3

R for Rubbers & Lube

  • Unprotected (without a condom) sex with a new/casual partner carries a risk of contracting STIs or blood-borne viruses.
  • Stock up on condoms and lube, keep them in a cool place, practice using them and get confident in talking about using them before you go.

A for Alcohol & Drug Use

  • Be careful when having sex after alcohol use. With alcohol or other drugs, one is more likely to take risks: not using a condom, having sex with someone you normally wouldn’t have sex with. We encourage condoms to be used for all forms of sexual activity especially with new/casual partners.

*Note: We do not support illicit drug use and urge our readers to abide by the host country’s drug laws. Singapore has strict anti-drug laws. Any citizen or permanent resident found to have abused controlled drugs overseas will be treated as if he or she had abused drugs in Singapore. Furthermore,  possession, consumption, manufacturing, import, export, or trafficking of controlled drugs in any amount are illegal.

V for Vaccinations

  • Discuss with our DTAP team the risk of infections, STIs and Blood Borne Viruses and any vaccines that are available (plan ahead as some vaccinations may take up to 6 months for full immunity). The vaccines that we recommend are the HPV (human papillomavirus) vaccine, also known as Gardasil 9, Hepatitis A and Hepatitis B vaccination.

E for Education

  • Empower yourself with information where sex may be available, at your travel destination.4
  • Ensure you are vaccinated against Hepatitis B, carry and use kite-marked condoms, consider taking oral HIV PrEP (Pre-exposure Prophylaxis) prior.

L for Living and travelling with HIV

 
Get tested after you return and last but not least, consider PrEP before you travel!  Learn more about Travelling with HIV PrEP (Pre-Exposure Prophylaxis)

Safe Trip and Have Fun!
This article was written by Dr Tan & Partners, in collaboration with Oogachaga.


References

  1. Vivancos R, Abubakar I, Hunter PR. Foreign travel, casual sex, and sexually transmitted infections: systematic review and meta-analysis. International Journal of Infectious Diseases. 2010;14(10):e842–51.
  2. Svensson P.,et al. A meta-analysis and systematic literature review of factors associated with sexual risk-taking during international travel. Travel Medicine and Infectious Disease. 2018; Jul – Aug;24:65-88
  3. https://wwwnc.cdc.gov/travel/page/std
  4. https://www.fitfortravel.nhs.uk/advice/general-travel-health-advice/sexual-health-risks
  5. Riddell Jt, Amico KR, Mayer KH. HIV Preexposure Prophylaxis: A Review. Jama. 2018;319(12):1261-8.
  6. WHO Guidelines Approved by the Guidelines Review Committee. Guideline on When to Start Antiretroviral Therapy and on Pre-Exposure Prophylaxis for HIV. Geneva: World Health Organization Copyright (c) World Health Organization 2015.; 2015.
  7. Elsesser SA, Oldenburg CE, Biello KB, Mimiaga MJ, Safren SA, Egan JE, et al. Seasons of Risk: Anticipated Behavior on Vacation and Interest in Episodic Antiretroviral Pre-exposure Prophylaxis (PrEP) Among a Large National Sample of U.S. Men Who have Sex with Men (MSM). AIDS and behavior. 2016;20(7):1400-7.
  8. Brett-Major DM, Scott PT, Crowell TA, Polyak CS, Modjarrad K, Robb ML, et al. Are you PEPped and PrEPped for travel? Risk mitigation of HIV infection for travelers. Tropical diseases, travel medicine and vaccines. 2016;2:25
  9. Hampel B, Reinacher M, Fehr JS, HIV pre-exposure prophylaxis (PrEP): Is it time to rethink HIV prevention in travelers?, Travel Medicine and Infectious Disease (2018), doi: 10.1016/j.tmaid.2018.06.008
  10. https://www.iwantprepnow.co.uk/how-to-take-prep/

Top Travel Tips for Persons Living With HIV (PLHIV)

Planning for a long Vacation or Preparing for a Business trip? The travel preparation can sometimes be challenging for People Living with HIV (PLHIV).
Making sure there is enough medication. Making sure you get the correct travel vaccine or visiting the doctor to get prescription (just in case you might be questioned during immigration check)

Travel Tips For Travelling with HIV (B.R.A.V.E)

B for Board, Bottle

Carry Your HIV Medication with You on Board
Carry your HIV medications with you on Board rather than checking them in and have a memo from the prescribing doctor’s memo with you.

Carry Your Doctor’s Memo with You
The contents of the memo should confirm that the medication is necessary during the trip. It does not need to discuss HIV and can state the medications are for a chronic medical condition and for personal use.

Use Medication’s Original Packet or Bottle
It is also advisable to have the medication’s original packet/ Bottle, showing the name of the person carrying the medication and medication details.

R for Reveal, Reiterate

You Don’t Need to Discuss Your HIV Status!
When crossing international borders, one might be questioned on the medication carried. Preparing for these questions can facilitate an easier border crossing experience. HIV need not be discussed or Revealed and that these medications are for a chronic health problem can be Reiterated.

A for Adjust, Avoid,  Anonymous Testing, Advice

Adjusting Your Dose Timing
Discuss with your doctor dose timing adjustments when travelling across different time zones. Medication can usually be taken one or two hours later for a number of days until the timing fits with the destination country. The process should be reversed on return.

Avoid Missing Your Medication Dose
Missing medication doses should be avoided at all cost. Treatment breaks should be avoided unless discussed with your doctor.
 
 Advice, Anonymous testing
If you are travelling in and out of Singapore and need advice on HIV treatment or testing, At Dr. Tan & Partners, we provide a safe and discreet environment for testing. You can find out more about Anonymous HIV Testing.

V for Vaccinations

General principles for vaccination of PLHIV as follows:

  • Killed or inactivated vaccines do not represent a danger to immunocompromised people and generally should be administered as recommended for other people.
  • Live-virus or live-bacteria vaccines such as BCG, oral poliovirus, typhoid (Ty21a), varicella, Yellow fever should be avoided unless the benefits outweigh the cons

The main vaccinations we recommend for PLHIV besides the country-specific vaccinations are.

  1. HPV Vaccination
  2. Hepatitis A
  3. Hepatitis B
  4. Influenza
  5. Pneumococcal
  6. Meningococcal

E for Extra Medication

Bring Extra Medication
It is imperative to bring enough medication and slightly more for a few days as getting a prescription or purchasing your medications in a foreign country may not always be possible. Furthermore, there is no way to ascertain whether the purchased medication might be of the same quality, type and efficacy.

If you are travelling with a partner/s who are not HIV positive, you can find out more information on getting PrEP (Pre Exposure Prophylaxis) for their protection as well – Non-HIV partners for HIV PrEP.

Here are some further resources you can explore to find out more about the country you are travelling to and its restrictions if any:
1.) www.aidsmap.com – HIV-related services worldwide and access country-specific information and news 
2.) www.hivtravel.org – International database on HIV related travel and occupation

Safe Trip and Have Fun!
This article was written by Dr Tan & Partners, in collaboration with Oogachaga.