Arjan (37) his PrEP application was put on hold

'My family doctor put my PrEP application on hold.'

You have to be fully vaccinated against hepatitis B before you start PrEP, the HIV prophylactic. Arjan (37) went to his family doctor well prepared, but despite that, his application was delayed considerably. “It turned out that I had been living in a false sense of security for about fifteen years.”

Before a doctor is allowed to prescribe PrEP, several important tests have to be performed. It has to be clear that the patient has not already contracted HIV, and the doctor must check for other STIs including hepatitis B. Proper kidney functioning must also be tested because in some cases PrEP can have negative effects on them.

Important prerequisite

A full hepatitis B vaccination course is an important prerequisite for PrEP. This doesn't matter for the efficacy, but when a person takes PrEP, they might have sex more often, with or without a condom, which increases the risk of hepatitis B transmission. This virus is very easily transmitted through contact with infected blood, sperm or pre-ejaculate, but also if your penis or anus touches the penis or anus of someone who has the virus. Condoms reduce the risk of transmission, but the only way to fully protect yourself against hepatitis B is by getting vaccinated. It is free for men who do it with men at the GGD (public health service).

“My family doctor put my PrEP application on hold. His thinking was: if I don’t, I might be protecting you from getting HIV, **but not against a chronic hepatitis B infection”

Evelien Siedenburg, coordinator at the Hepatitis B Vaccination Programme at GGD Amsterdam: “We want to prevent people from getting hepatitis B and spreading it to others. If the person who gets it is unlucky, hepatitis B can become chronic which means that he woud have to be treated for it his whole life and has an increased risk of liver cirrhosis and liver cancer. Nowadays, Dutch children are vaccinated before they turn one, but many adults haven’t had the hepatitis B vaccin yet. This is why the GGD vaccinates groups who are at a higher risk of transmission, such as men who have sex with men.”

Not fully protected?

Arjan took advantage of the GGD’s offer 15 years ago. “When I had STI tests done at the GGD in Tilburg for the first time, the woman who helped me offered me a hepatitis B vaccine. I had it done but it was quite a while before I had the two follow-up shots. I didn’t show up for my appointment twice and and I didn’t dare to make a new one after that. When I went to the GGD in Haarlem to get travel vaccines for a trip to Mexico, they finally finished the series.”

Arjan had no idea that he wasn’t protected against hepatitis B, so when he went to his family doctor in 2019 to apply for PrEP, he was in for an unpleasant surprise: “I was planning to go to a great party, where there would be a good chance of having sex. I thought I’d do the smart thing and made a longe doctor. That would allow him to do all the tests and there would be enough time to see if I had any side effects.” Arjans’ family doctor followed the protocol and had him tested for HIV, STIs and had his kidney function checked. He also did a titer test, which checks the level of HIV antibodies in your blood.

The titer test showed no hepatitis B antibodies  in Arjan’s blood. “That meant that I had been living in false sense of security for about 15 years, which was a really weird feeling. Luckily the test also showed that I hadn’t been infected with the virus in all those years. But I suddenly realised that I could still get it. It is hard for me to figure out what kind of risk I’m at right now. My family doctor didn’t see it as a reason to put my PrEP application on hold. First I have to get vaccinated for hepatitis B again. His thinking was: if I don’t, I might be protecting you from getting HIV, **but not against a chronic hepatitis B infection.”

Titer test isn’t always conclusive

Arjan made an appointment for a follow-up vaccination on Mantotman.nl/onlinevaccinatie. “The nurse gave me the first shot and recommended getting a titer test six weeks later. It should show that I had started making antibodies now. Then I could get the second and third shots with only a month in between in order to speed up the vaccination series. But again the titer test showed nothing.”

So what is going on with the people who, like Arjan, are exceptions to the rule and do not seem to respond to the vaccination? “The results of a titer test are not always conclusive”, according to Siedenburg. “A titer test is supposed to show whether the vaccination has been successful four to eight weeks after your last shot. If you finished your series of vaccinations ten years ago, a titer test may show you don’t have enough. However, this doesn’t necessarilycf mean that you don’t have them. In most cases, a full series of vaccinations provides lifelong protection against hepatitis B. The vaccine program at the GGD does not include a standard titer test. We assume that the vaccine will protect you from hepatitis B throughout your lifetime, and this is true in most cases. However, if you want to know for sure, you can ask your family doctor to have you tested. If you want to take PrEP, they will need to know if you have hepatitis B or if you have been inoculated against it. A negative titer test is no reason not to prescribe PrEP, but you need to realise that you may not be completely protected from getting hepatitis B. You can reduce this risk by using condoms in addition to taking PrEP.”

Hepatitis ABC - get your shots on time

The hepatitis B vaccine consists of three shots spread out over 6 months. They are free for men who have sex with men. Are you planning to start a PrEP course, but you still haven’t finished your vaccination series? Then now is the perfect time to plan your next shot. You can get the hepatitis A shot at the same time. It is not free. Ask about it at your local GGD (public health service). You can make an appointment on Mantotman.nl/onlinevaccinatie.

There is not vaccine against hepatitis C. At NomoreC.nl you can check to see if you are at risk of getting hepatitis C and find tips on how to reduce that risk. You can also order a hepatitis C home testing kit.

How PrEP affects hepatitis B

Hepatitis B has no effect on the efficacy of PrEP, but PrEP does affect hepatitis B. The virus is suppressed by the ingredients in PrEP. If a person who has hepatitis B and uses PrEP before and after sex, or stops taking it daily after a while, may experience a surge of the virus. If you aren’t yet using PrEP, you may want to talk to your doctor about whether starting PrEP or switching to a daily PrEP regime is an option. Taking PrEP only before and after sex is not recommended if you are infected with hepatitis B.

Editor's note

Men to Men regularly interviews men about how they protect themselves against HIV and STIs as well as their experiences with sex. We believe it is important for people to be well-informed and are able to make informed decisions on how to protect themselves. We hope that the variety of personal stories of people’s experiences help them with this. They do not necessarily reflect Men to Men’s standpoint. This story was published on Winq.nl.

We used a stock photo for this story as Arjan wished to remain anonymous.

Text: Martijn Tulp
Stock photo: 123rf.com

Would you like to share what steps you take to protect yourself against HIV and/or STIs?
Contact Men to Men