How to take PrEP on the other side of the world

Taking a pill once a day sounds simple. But what happens when you put the intricacies of travel into the mix?

This article was originally published by Xtra’s sister publication Pink Ticket Travel.

For some people, travel isn’t only about trying new foods, discovering different cultures and seeing the sites; it’s also an opportunity to make new friends, friends with benefits or sex partners. Studies have found that people tend to increase their sexual activity and their number of sexual partners when they are travelling.

“I know from working in the sexual health field that some people travel with the awareness that they are going to be sexually active. And some people travel and, well, they just find themselves in a situation where they happen to be sexually active,” says Dr. Caley Shukalek, chief medical officer of Calgary-based PurposeMed platform, which aims to improve healthcare for underserved groups, including through the service Freddie. “We should be prepared either way.”

For many in the queer community, being prepared means taking PrEP, which stands for pre-exposure prophylaxis. It’s a once-a-day medication used to prevent HIV infection in those who are at risk of being exposed to the virus. In Canada, it’s often recommended to men who have sex with men and other members of the LGBTQ2S+ community, though some studies suggest there are fewer people in Canada using it than healthcare experts would like. 

Taking a pill once a day sounds simple. But, like many medications, PrEP usually comes with instructions that it should be taken at the same time each day. What happens when you are on the road and taking PrEP at that same time every day isn’t convenient, or when “time of day” isn’t so clear? For example, say you live in Toronto, where you take your daily dose at noon, but you’re vacationing in Hawaii, where there’s a six-hour time difference. Do you set an alarm to sleepily take it at six a.m., or do you continue taking it at noon? If you’re moving from time zone to time zone, do you need to keep changing the time of day when you’re taking PrEP, which might lead to missed doses? Should you change the time you take it in steps, maybe one hour at a time, or immediately?

“The honest answer is pretty simple,” says Shukalek, who specializes in sexual health and HIV care. “For people who are using PrEP on a daily basis and not regularly missing doses—which is the majority but not 100 percent of people who use PrEP—you are going to have a good amount of medication in your system, and you can pretty safely continue taking it at the same time of day, even if there is a 12-hour difference.”

Shukalek says the medication concentrates inside the white blood cells and other cells in your system that HIV likes to infect. So as long as your schedule isn’t off by more than 12 hours or so, he said there should be enough medication in your body to fight infection. “It is pretty forgiving, but I wouldn’t want people to miss doses repeatedly, days in a row or every other day,” he says.

“I take my pill in the morning, and that is anywhere from eight a.m. to noon. It is forgiving enough that you can do that every day. As long as you are getting a dose in, your drug levels will stay consistent.”

Drew Schonbe, also known as Pharmacist Drew, is a certified HIV pharmacist and the founder of The PrEP Clinic, which offers in-person services at clinics in Toronto, Brampton and Ottawa, and internet-based care to those facing barriers to access. He said that time variations of 12 hours or less should be okay. Although most studies focus on cis men and trans women, both Schonbe and Shukalek agree that the 12-hour variation also applies to trans men and cis women.

“We don’t encourage people to miss doses, but if someone is consistently on PrEP and they have taken a dose later in the day, beyond the 12 hours, or they even miss one pill very rarely, their protection would still be quite significant,” Schonbe says. “If somebody needs to change their scheduling a bit, by several hours, that is fine. They can just shift to that schedule. When they come back from their trip, they can switch back to what works for them.”

Legal issues around PrEP

The issues around PrEP and travel don’t stop at when to take it. Schonbe says PrEP users need to understand the laws of the country they’re visiting. PrEP is considered an HIV medication—albeit one that prevents infection—and those are restricted in some places.  

“There is obviously a risk, and people need to be aware of that. Potentially it may be confiscated, or it can even affect their ability to enter that country,” says Schonbe. “I always recommend you check with the border or travel agency for the country you are travelling to, and that includes any places where you may have a stopover if you are flying, or docking if you are on a cruise. Some countries are very draconian in how they address HIV treatment and prevention.” In 2019, U.N. AIDS reported that 48 countries had HIV-related travel restrictions. 

For travel in Asia and the Pacific, summarizes important information about local PrEP access, import restrictions and information on local sexual health testing. For example, Australia allows visitors to bring only a three-month supply of the drug, while Japan limits it to one month. Sri Lanka requires travellers to have proper documentation, like a doctor’s prescription note. 

There is also a risk that PrEP, or any other HIV-related medication, might identify you as a member of the LGBTQ2S+ community in countries with anti-homosexuality laws. A list of those countries and specific laws are available on an interactive map on the ILGA World Monitor website.

The U.K.-based HIV/AIDS charity aidsmap reports that it is not aware of any country that bans PrEP outright. Yet, “if a country has entry restrictions for people with HIV, travelling with PrEP might cause problems. This is because customs officials might think the medication is for treating HIV. In extreme cases, it could even mean you are deported (made to leave the country). A letter from your doctor explaining PrEP is for HIV prevention might help.”

Schonbe recommends that patients tell their pharmacist that they’re travelling, and to bring a prescription and travel letter with them to have fewer challenges from officials. He also suggests keeping medication in the bottle it’s prescribed in. “When you are travelling to another country, [you don’t want them to wonder], ‘What is this pill?’ They are going to see that it is in the appropriate bottle, the bottle has your name on it and that matches your travel information,” he says. “It is not the discrete way to do it, but it is the safest way.”  

Doxy-PEP, PIP and other considerations

Being smart about PrEP is not merely thinking about logistics and scheduling. Typically, people taking PrEP are tested for HIV and other STIs every three months, so Schonbe suggests getting the next round of lab work done before your departure. If any STIs are detected, travellers can address them before hopping on a plane.

Schonbe also recommends researching ahead of time what sexual health resources are available at the destination. If you pick up an STI abroad, how easy will it be to have it treated? For those who plan on having sex without condoms, it can be a good idea to travel with a supply of Doxy-PEP. It’s a medication—or perhaps better described as a strategy—that can prevent syphilis, gonorrhea and chlamydia if taken after exposure.  

For HIV specifically, PIP, an abbreviation of “PEP in Pocket,” is another option for people who don’t take PrEP or who regularly miss taking their pills. It’s an HIV-prevention strategy that involves taking PEP, post-exposure prophylaxis, immediately after possible exposure to HIV. Though it’s not 100 percent effective—and the decision to take it can be more stressful than just taking PrEP daily—it can dramatically reduce the chance of infection, and can be a cheaper option than paying for daily PrEP.

On your return home, if you were sexually active on your trip, Shukalek says you should see your healthcare provider and get tested. “There are infections that are common in other parts of the world that are not common in Canada,” he says. “Make sure you tell the provider that you were travelling and where you were, because maybe they need to do a different test or to consider something different then they would for patients who are just sexually active locally.”

Dean Lisk is a culture, entertainment and travel writer whose work has appeared in publications including the Globe and Mail, Toronto Star and Metro NY. He is the former entertainment and lifestyle editor at Metro English Canada and past editor of WestJet Magazine. He is currently based in Toronto, Canada, and can be followed on Instagram @deanlisk.

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