MSM 101 and Great Craic with Dr Fergus McCabe

Ah here, if your sex education came from a bloke in Coppers at 2am, this one's for you.

We're joined by Dr Fergus McCabe, GP and sexual health expert, to give us the essentials on Men Who Have Sex With Men (MSM). 

We owe a lot to MSM, who fought tirelessly for the improvement of healthcare, and we are here to tell you why. We also cover the essentials - MPOx, PrEP and DoxyPep. 

We love acting the maggot with Fergus but we promise you, he knows his onions. 

Listen to this one and you’ll be grand. It’s good craic. 

Find us here!

Instagram: @fgsx_pod
Email: fgsx.pod@gmail.com

Resources here!

M Clinic: https://www.mclinic.org.au/
Little Book of DoxyPEP: https://www.thelovetank.info/news/doxypep
SHQ PrEP info: https://shq.org.au/resources/health-info/info-sheets/prep-brochure/
WAAC MPOx What You Need to Know: https://www.waac.com.au/mpox/

Guidelines here!

ASHM PrEP Guidelines: https://ashm.org.au/resources/australian-prep-guidelines/
ASHM Decision Making in DoxyPEP: https://ashm.org.au/resources/doxy-pep-decision-making-tool/
MPOx Alert: https://sti.guidelines.org.au/sexually-transmissible-infections/monkeypox/

We are your co-hosts, Dr Shyamini and Nurse Ellie, and this, is For Goodness Sex xx

Transcript

SPEAKER_03 0:00

Hello, my name is Shamani, and I am a co-host of the podcast for goodness sex. I am a Fijian Indian woman of immigrant parents and am proud to live, work, and play on Rajakunyunga country. This podcast acknowledges the past, present, and future traditional custodians of stolen country and the impact this has had on the health and well-being of our Aboriginal and Torres Strait Islander brothers and sisters. Sovereignty was never ceded.

SPEAKER_01 0:27

Hi team. Now, whilst we are healthcare professionals, this episode is for informational purposes only, and it does not replace personalized healthcare advice. Your health is unique to you. If you have healthcare concerns, please seek out your local health professional. Nailed it. Nailed it. Nailed it. Nailed it. Absolutely nailed it. Thank you, Bag.

SPEAKER_05 0:49

Which in Dublin, as we say, is better than a schlep in the eye with some shit in the end of a stick.

SPEAKER_01 0:53

Sorry. Sorry.

SPEAKER_00 0:55

Okay, sorry.

SPEAKER_04 0:56

Okay, sorry.

SPEAKER_03 1:16

And this is for goodness sakes.

SPEAKER_01 1:37

Hi Dolph. Hi. How are you? I'm doing good. Good. Yeah. Considering yeah, yeah. So my car started shaking uncontrollably on the way to work this morning. Shame. Yeah, yeah. So luckily I didn't get on the freeway. And I was like, maybe it's just cold. Well, honestly, I thought that it was. Because I was like, she just needs to warm up, it's fine. Yeah. Just kept driving. I was like, she'll warm up. She'll get into it. But no, she just jostled more and more. So I didn't get on the freeway, which is good because I'm alive. But yeah, she's been towed. We prefer you alive. I do too. Yeah, yeah, yeah. So yeah, we'll we'll keep we'll keep waiting to hear from the mechanic. See what they say. We're not sure if it was a mechanic. We don't know yet. Yeah, I uh haven't heard from them. But yeah, are you good? Yeah, I am good. I'm having a good week. Okay. Busy.

SPEAKER_03 2:25

Had a six-day work week last week.

SPEAKER_01 2:27

No, that's too many days. Too many days.

SPEAKER_03 2:29

You know, si you know, one day is too many.

SPEAKER_01 2:31

Agreed.

SPEAKER_03 2:32

Anyway, um shall we get cracking? Yeah, go on. So today we have a guest. We're loving our guests. We're smashing through our guests. We sure are. Not physically, guys. Calm down. Okay. So Dr. Fergus McCabe is a highly regarded Perth-based general practitioner specializing in sexual health. And in particular, HIV medicine. Originally from Ireland, where he was the first male to study speech pathology. Cool. Yeah, yeah. What? He moved to WA in 1990 and started his medical degree in 1997 in Adelaide. In the pursuit of infectious disease medicine, he started his physician training in Fremantle. But after moving back to Dublin, where he worked in HIV and addiction medicine for nine years, he returned to Australia to do GP training and has been a fellow of RAC GP since 2014. Fergus is also the medical governor of WAA's Council's M Clinic, and in 2025 was named Gilead Science's Health Ally Community Champion in recognition of his relentless pursuit of the betterment for people living with HIV. Wow, I know. When not at work, you'll find him forgetting he was supposed to be at work or at his other work or at his other work or at a meeting. Stop it. I know. Or spending quality time with family and friends. Whilst Fergus is a respected health professional, he is also a powerful storyteller with a charming wit and an infectious laugh. He has an engaging but humble presence and is so loved by everyone around him. Not only am I lucky enough to work with Fergus, but I'm also lucky enough to share a healthy rivalry on who can stir the most shit or crack the best jokes at each other's expense. And unlucky for him, I always win.

SPEAKER_05 4:14

I didn't think you were in the competition. Okay, well that's Wonder Fergus.

SPEAKER_01 4:19

Wonder Fergus so far.

SPEAKER_03 4:21

Welcome, Fergus! Thank you very much. Oh, you're so welcome. Where did you get all that information? Our website. Wow, it is an honor.

SPEAKER_01 4:29

And it is an honor. That is an amazing intro and bio. Yeah.

SPEAKER_03 4:35

Yeah. We actually Fergus gave me my job and my current practice.

SPEAKER_01 4:39

I think I knew. Yeah, that's that's awesome.

SPEAKER_03 4:40

Yeah. Yeah.

SPEAKER_05 4:41

Do you want to know why? Well, we were I was I was giving a uh talk at an S100 GP training for HIV. She asked three questions, and I said, Meet me at tea.

SPEAKER_01 4:52

Oh my god, that is so cool. And then can I ask what the three questions were do you remember?

SPEAKER_03 4:57

No, but they were very insightful. I bet. And then he was like, I think we have a broom closet for you somewhere. Perfect.

SPEAKER_01 5:02

Shawnee loves brooms. Oh my god, you were scouted.

SPEAKER_05 5:07

I know, I know. Yeah. Sometimes, sometimes you just make fundamental mistakes.

SPEAKER_02 5:13

To this day, don't we know it's a single day.

SPEAKER_03 5:17

She lingers and she's right. So um before we reveal the episode contents, I actually wanted to do a true or false. You're a bitch.

SPEAKER_01 5:30

No, she's strong. She hates it. No, no, go on. Go on. Let's get the buzzer on.

SPEAKER_05 5:36

I just remind you I'm your boss.

SPEAKER_03 5:37

Oh no. You're gonna get it right. You're gonna get it right. It's gonna be fine. It's gonna be fine. It's gonna be fine.

SPEAKER_01 5:42

I didn't I didn't prep as much as I wanted to for this because I had a really stressful day. That's all just remember.

SPEAKER_03 5:47

So it's okay. I do want the buzzer.

SPEAKER_01 5:50

We're gonna have a buzzer for true or false. Good. Just to just because my generalized anxiety sort of isn't enough. Let's add a buzzer. No, I'm kidding. I'm excited. Let's do it. Also, first um male speechy in Ireland. Yes. Dublin. Yes. That is so cool. There's a good story behind that. Oh my god, I can't wait to hear. Yeah, tell him.

SPEAKER_03 6:12

We love stories.

SPEAKER_05 6:13

Do you know Noam Chomsky? Nice short short.

SPEAKER_03 6:16

Is that an incense brand? It's hard. You were born in 1945, I guess. It's really hard for us.

SPEAKER_05 6:22

But Noam Chomsky is a very famous American uh philosopher and linguist. Oh. But I thought I just I just knew him by his political books and political commentary. And he uh came to Dublin to give a talk. And when I went and spent the night watching him at this talk, and I realized he's actually a linguist. And at the end of the chat, at the end of the lecture, I went and uh had a chat with him. And at the end of the chat, he said, What are you doing here? And because all I spoke to him about was his politics and his political books. And I said, Oh, I didn't know you were a linguist. I I just thought you were you were right you were a political commentator. And he said, Yeah, because I wasn't a kid, he asked me what I was gonna do, I was gonna do medicine. And he said, Have you heard about speech pathology? And I went, No. And he told me what it was. And he said, You know, you do a lot of this linguistics, but it's also medical. I went home, changed my application. Oh, okay. Got a phone call the next morning because no mail had ever applied. It would be got in the next day. And then remarkably, for somebody who went to school in the 70s and 80s in Ireland, uh, when I went to I went to university, it was the first time I was ever taught by a nun. Sister Marie de Montfort Sutton.

SPEAKER_03 7:25

Oh, is this is this the story about the the dildo as well?

SPEAKER_01 7:29

Oh, that's another story.

SPEAKER_03 7:30

That's another story.

SPEAKER_00 7:32

The nun story. Do you want to tell that story?

SPEAKER_01 7:34

So glad this room isn't drafted. You want that story?

SPEAKER_00 7:36

Oh I love that story. I want to hear the story about the nun and the dildo, absolutely.

SPEAKER_05 7:41

So so the school of speech therapy was in uh Trinity College, which is an old, old university, but the head of school was this nun called Sister Marie de Montfred Supple, right? Sorry.

SPEAKER_03 7:52

Sister de what?

SPEAKER_05 7:54

Sister Marie de Montfred Supple. Supple. Supple. Supple button. It was just me and and twenty odd girls. And they were mostly all from rural country Ireland and convents. And uh after about maybe a year, we went on a to a uh student conference in London. And one of the one of the girls in my class, Catherine, who's fantastic, was was classic sort of Irish Colleen, very flowing long hair, and caught always talked about that she was gonna be a nun. That the nuns had she was a single daughter, single child, and very elderly parents. Um from and she was from a little small farm in Ross Common. And uh the the nuns had had got their hooks into her early, right? And we're gonna make her had recruited her, right? But but rather uh uh uh funnily for for the time, Catherine in the middle of you know this conservative Irish uh university would say, Oh yes, yes, yes, I've got a vocation, I'm gonna be a nun, but I'm gonna get fucked once first.

SPEAKER_01 8:55

Get it, Catherine! Catherine's priorities in order.

SPEAKER_05 8:59

So we so we went to this conference in London, and at the time Dublin is a modern, multicultural, fantastic place now, if you get a chance to go. I the Dublin I left was a kip. Now it's just amazing. It's post-colonial. It's left go, it's it's let it go the shackles of the British Empire, and it's found itself. It's great. Um, but uh yeah, so we we we went to London, and London was a huge, big metropolis, and it had sex shops, and Dublin didn't have sex shops. So I'm walking through London with 20 odd girls, and we walk past Leicester Square and there's a sex shop, and Catherine just goes like a beeline.

SPEAKER_01 9:33

Yes, Catherine.

SPEAKER_05 9:34

And everybody sort of stops and goes, Oh my god, what's going on? So we waited and we waited and we waited, and she didn't come out, she didn't come out, and then somebody went in and then we waited and they didn't come out, and then somebody else went in and we waited and waited and they didn't come out, and then eventually Catherine comes out, going, I need five more pounds, I need five pounds, five pounds, right? And everybody's sort of whipping around and went, What do you need five pounds for? And eventually we all went in with her, and she went in, and there was literally just a line of dildos, right? And there's this guy fully tat, sort of behind the counter, and she walked up to him and she said, Excuse me, does this reverberate at less than 250 beats revelations per second? And the guy didn't even blink, right? He just went, Hold on, darling, I'll ask the technician.

SPEAKER_04 10:16

Stop it!

SPEAKER_05 10:18

And he just flipped around on his on his heels, walked straight through the beads, you know, those right, walked through the beads, did a full 360, walked back out, went, Yeah, the technician says it won't do you any harm at all, darling. Oh my god, right? That is brilliant. And uh and sold her the dildo. So we thought the end of that. Anyway, so first thing back at uni on Monday, first first lecture on Monday morning. The first lecture we have is with Sister Marie de Montfort Supple, and we're all sitting in this little lecture theatre. And because these girls had all gone to convents, they were used to playing pranks with their nuns and things. So we were sitting there quietly, and then all of a sudden, Catherine jumps up, runs up to the front and onto the lectin, and puts the dildo on the lectin and turns it on, right? And then sits back down again. Everybody's sitting there, and this thing has gone on the lectin, right? And the nun walks in, sees this dildo that's going, didn't flinch, didn't flinch, picked it up, and she's going, What's this? What's this, right? And Catherine tells her what it was and tells her and tells her the story, right? And it turns out that Catherine had read a paper that showed that if you for for patients who've got dysarthria post-stroke, that if you use vibration at less than 250 revs per second, you don't cause muscle damage and you enhance blood flow and it imp it improves dysarthria. So it's speech therapy with a dildo.

SPEAKER_01 11:39

Get out and so the nun thought this was absolutely hilarious.

SPEAKER_05 11:43

That isn't it. Walked out of the class with the dildo in her hand and went around all of the other lecture theatres in the school, going in, telling all the other lectures and all the other students what the what what this story of what Catherine had done. And then after 20 minutes, 15, 20 minutes, came back into the room, sort of tears rolling down her eyes, and very, very, you know, had obviously been laughing, and hands the dildo back to Catherine and then turns on, turns around and walks back to the top of the lecture theatre. And just as she gets to the top, she turns around and looks at Catherine and said, Oh, by the way, why are the batteries so flat?

SPEAKER_01 12:16

Oh brilliant. What a story. Brilliant.

SPEAKER_00 12:27

Very, very good.

SPEAKER_01 12:28

Oh, that's great. Love that. I love that you were. I love it. I was quiet, quiet, quiet witness. Maybe you drained the battery.

SPEAKER_03 12:41

All right. Let's get into it. Okay, let's go. Yes. True or false? The term AMAB or assigned male at birth refers to someone's sexual orientation or who they have sex with. False. False. Great, good. It's not gonna be bad. I thought it was a trick too. I was like, I was like, hang on a minute. I'm I'm pitching to my my crowd, obviously. No worries. Some men who have sex with men also have sex with women.

SPEAKER_01 13:15

True.

SPEAKER_03 13:16

HIV and other STIs can be transmitted through unprotected sexual contact, regardless of sexual orientation. True. Guys are three out of three. Stunning. Only people who identify as gay are at risk of HIV. False. Mpox only affects men who have sex with men. False. Okay. Pre-exposure prophylaxis is a medication that can significantly reduce the risk of acquiring HIV when taken as prescribed. True. Okay. So you guys are so good. Some men who have sex with men identify as heterosexual.

SPEAKER_01 13:52

True. True.

SPEAKER_03 13:53

True. Vaccination can help protect certain populations from infections, such as hepatitis A, B, human papillomavirus, and empox. True. Doxype protects against all STIs. False. Empox can only spread through sexual contact. False. Okay, final question. Charmoni is cooler than Fergus.

SPEAKER_00 14:16

Oh my god!

SPEAKER_01 14:17

True. I played the fifth. No comment, no comment.

SPEAKER_00 14:24

You guys are so good.

SPEAKER_01 14:25

Yay! Thank you. Maybe I do know who it is.

SPEAKER_03 14:31

So I guess I had originally wanted to silo this episode to discuss men who have sex with men. Great. And how specific sexual health issues that arise within this subgroup, but we were actually, as you were reviewing the questions at the crack of dawn last night, you made a really good point that using the acronym MSM as a subgroup can be quite stigmatizing.

SPEAKER_05 14:53

Can I just clarify that? So I I wasn't making the point that using the term MSM was stigmatizing. I was using I was saying that if we try and just uh uh quantify or discuss sexual risk in time in terms of MSM, that that's stigmatizing.

SPEAKER_03 15:07

Right, okay. But the actual term MSM is fine.

SPEAKER_05 15:10

Yeah, I think it's that the term I mean it's a medical term, right? Yes, yes. It's a medical term that exp that explains or allows for the fact that there are lots of men that have sex with men who don't identify with being gay or homosexual or other terms that they use.

SPEAKER_03 15:23

Okay, as we've uh just identified in our true or false. So the issue with identifying specific risks within this population is sil is stigmatizing rather than the population itself.

SPEAKER_05 15:33

I think we have to be careful. I think there are specific risks, risks, but I think we have to be careful how we phrase it.

SPEAKER_03 15:38

Yeah, so I guess can we can we talk a bit about that and why why it is stigmatizing?

SPEAKER_05 15:43

Yeah, so well I I mean I you know, obviously the that I always feel a bit cheeky having this conversation because I'm not a gay man or you know, or a man who has sex with men, right? I just have a lot of professional contacts with with with that population over time. And so you you're better off having a conversation with somebody who actually hasn't has that lived experience, yeah, right. But my my impression or what I've learned from that population is that you know they've had to fight a fight for a long time. Yeah. A long, long time.

SPEAKER_06 16:10

Yeah.

SPEAKER_05 16:10

You know, you know, like I I think even as a as a profession, I I make this point a lot, as a as a professional, even as a uh the the whole fraternity of medicine and the patients that we deal outside of sexual health owe that population a huge debt of gratitude because of the fight that they fought and that that fight's crossed over into medicine where patient-directed care and listening to the patient or listening to the patient's care or partner has become more normal than it was when I first started working with HIV. You know, there'd be a there'd be a cohort of professorial like doctors running through a room with lots of doctor junior doctors, nurses, and medical students behind them firing off questions and treatments, but not actually listening to or having a conversation with the patient in front of them. And it was them the if the if the patient was too sick as they often were at the time, it was their partner who went, Whoa, whoa, hold on. Who who are you? What are you doing? Why are you saying that? Why are you giving that? What's the benefit of that? What's the harm of that? Why haven't you thought of this? I've read about this. And and the doctors, the older generation of doctors at the time, were very confronted by that and had to, you know, move into the 20th century very quickly. And I think there's there's that because that population have fought had been had fought that social fight to be accepted, yeah, right? That's sort of spilled over. And and because of that, there's there's quite a bit of stigma that goes with that. Uh I mean I think I think you know, you'll you'll have this experience yourselves because you work in in the area, but most of our patients will tell us, will tell you that the the vast majority of the of the time that they face that stigma, it's actually from people in the medical profession. Yes, yes, 100%. Which is just not acceptable.

SPEAKER_03 17:53

Correct. Yeah, it's not at all. Yeah, yeah.

SPEAKER_01 17:55

It's such a beautiful thing to acknowledge. Yeah, what do you think? Yeah. Yeah, I mean, it's I actually haven't thought about it that deeply before, which I'm kind of embarrassed to say. I'm a queer person myself.

SPEAKER_03 18:08

No, I am too, because I obviously when I wrote these questions, I was like, oh, this this feels like a reasonable question.

SPEAKER_05 18:13

And when you pointed out that it was probably stigmatizing us, it was just the way it was catched in terms of saying like how many, you know, what are the the s the statistics for STI words? MSM. It's like as if oh only only people who have sex with men get STIs. I know you weren't saying that, but it was like you know, it's anybody who's sexually active can get an STI. Yeah, I see what you say. Okay, there we might swab a different site, right?

SPEAKER_03 18:37

Yeah, it's not like I would say like what are the stats in women, heterosexual women that get STIs, right? Like that's a similar thing about siloing. Yeah, that's right. And that that kind of did that with the question.

SPEAKER_01 18:46

Um it is tricky though, because you know, as we we put them in this high-risk category, you know, because we were uh like MS people who are MSM um is like categorized as like potentially a high-risk population, right? Which obviously, you know, where we want to make sure that we're doing the right thing with public health and doing this for you and keeping everyone healthy. But I remember like when MPOX first started and it was over in Europe, um, like one of my friends who's a gay man got it in Europe. And I remember that he sort of like went on this huge rant um that like ended up ended up being interviewed by the ABC and kind of just being like, and I don't know if this is going off topic again, but sort of just being like when MPOX first came out, like they felt like it wasn't really educated to actually like the gay men population, that this is kind of where it was circulating. Like they felt like that wasn't clear, like they felt like everyone had been like, oh it's fine, you can catch it anywhere, you know, like it's all through populations because the fear of that of our history. Yeah, that's exactly right. So he just said, like, I kind of wish someone had like towed the hard line of me and been like, you know, if you're doing this, having casual sex lots of casual sex with other men, just take a beat, stop for a bit. Because yeah, he he ended up getting empox and had that whole experience. So it it is interesting, you know, how that shaped us and how we handle things now. Yeah. Yeah, that's true.

SPEAKER_03 20:05

Yeah, and I think I think you've just highlighted the importance of language as well. True. Like a lot of sexual health is is language, so how we use it and and what that kind of means in terms of communicating with patients and our colleagues.

SPEAKER_05 20:16

So I mean I think like if you're if you're if you work in in public health, and like MPOX is a great example of this. If you if you want a population to get a transmittable disease, you want it in the MSM population because they are incredibly educated, incredibly compliant. Exactly. They get tested, they link in, they if you if you know if you're diagnosed somebody with like happens all the time. I I could diagnose somebody with syphilis, and then I'm talking to them and they're texting, and I'm going, hold on, mate, are you paying attention? I'm talking to you about these syphilis. And they go, Yeah, I'm just letting my contacts know. Right? So there's when you know they're they're they're you're right, they're they're incredibly uh educated and they educate each other, yes. Uh and they're incredibly responsive and responsible in terms of that. But I suppose what what the fear is and the fear from the public health term, even the change, even the use of the term that it was it was called empox because in 1958, when the Danish scientists that identified it, they identified it in a monkey, but it actually isn't a monkey virus at all, right? It's a rodent virus that's uh the monkey was the same as a human, it's just a vector, you know, in between. But the the stigma that goes with that, yeah, saying that oh, this population, it's exactly you know, and it was very triggering. It'd be interesting to know if there's a difference like your friend at his generation compared to somebody in their 50s or 60s who had lived through the AIDS epidemic and how triggering that was. Yeah. Yeah.

SPEAKER_01 21:38

We should get some we should ask some people. We should have population differences, I suppose. Yeah, I can absolutely do that. Yeah.

SPEAKER_03 22:00

Can you tell our listeners what it actually is and the significance of it? Yeah. Yeah. Is that okay? Yeah, yeah.

SPEAKER_05 22:07

So it's it's a it's a it's a virus that's in the same family as smallpox. Right? It's originally a virus that comes from Africa. Uh the the clade two virus that we have here is the is from West Africa, originally from a squirrel, a rodent type squirrel, and a number of different small mammals, and then as as happens in in uh like with COVID and with and with Ebola and things like that, you you know, we encroach on the on the natural habitats of these species and and put pressure on those ecosystems, and then you get a transfer from animal to human. You know, there was probably like with all of these things, there were probably a series of coincidences that occurred one after another that have have meant that Mpox has gotten into a population where it can spread easily. It's not the first time it's we've had outbreaks. You know, there was an outbreak in in the 90s in the States that were it was reflected around a uh a vet practice that actually had uh one of these squirrel rodents uh from West Africa that then transferred over to prairie dogs, and then the prairie dogs the prairie dogs scratched and and bit a few people, and then so there are a few cases, human cases in of empox in the nineties. In the nineties, I think it was Denver or Texas, and it was all it was all around this imported animals and this one particular veterinary practice, right? Well, and then it stopped right because it's not easy to transfer. You then go, okay, you've got COVID lockdown, everybody's locked down, and then there's the the the coincidence that at the time of everybody lifting from COVID because the vaccine is so effective, just wanted to put that in there. Nice, nice. Tell us how you really feel that uh you know, a uh MS, a man who have sex with men who happen to be from the West African region and who happened to have contact with the animal and catch the Mpox virus went to pride in the canaries. And and then you've got a virus that transfers easily through skin to skin, close close contact, lends itself to uh to being an STI. It it's it it is it we find it, this the studies that find it viable DNA, well sorry, DNA in semen, which might mean that it might mean that's the reservoir that allows it to spread in that population.

SPEAKER_03 24:25

Is that where the human transmission happened in the MSM population initially?

SPEAKER_05 24:30

So no, it it looks very likely the the transmission happened skin to skin. Yeah right? And then there was there were because of the the sort of explosion of activity at once the once the valve of of COVID was let go, and there was there was a a couple of cases from the caner the canaries uh pride that then went to, I think it was in Portugal, a pride event in Portugal. Like similar big events, it just found a population where it can spread easily because of this close skin-to-skin contact, and perhaps because of the the fact that it it let it can stay in semen for a long period of time. Right. So it just happens to have found a population that trans i it it can transmit well with, right? So because of that, we've we've had I think it's 180,000 cases uh since 1920 since 2022. Um in WA, we've had uh a few outbreaks, very well controlled. Uh we've got a currently got our largest outbreak. Of the last time I looked, it was 31 cases in the most recent outbreak, which is equivalent to a little bit more than the number of cases we had in all of last year. I definitely think we've it's it's now in the background in the community. This this isn't introduced virus like it was initially in 2022, whereas you could link it with travel or people who had been traveling or who had had sex with somebody who had been traveling. This is this is i uh in indigenous virus that's now circulating. Because of our our MSM population are so responsible and so receptive.

SPEAKER_01 25:58

It's the hets that we're blaming. The hets have ruined it for us.

SPEAKER_05 26:04

Yeah, we've got we've got we've been able to control it for a number of reasons. One, because there are so many people have been vaccinated, two, because they're so compliant when they get symptoms, they respond, right? And they come in, they get tested, they give us all of their contact details. I mean, you know, I I I I think I diagnosed three cases on the long weekend recently, and I mistakenly thought that public health wouldn't be available on a late on a Saturday night on on uh on a long weekend. So I started. Yeah, yeah. So I started to do the contact tracing myself, and I was calling people and then getting them to come into me. They had no idea who I was. And after 30 minutes, we're giving this were giving me all of their contacts and saying, Okay, here you go. And you do it, you can do this. It's very important for your listeners to know that's all done anonymously. Nobody's told who the contact is, you're just told you may have been exposed to a sexually transmitted infection if you've got symptoms. Please come in. Yeah. Now, as it happens, public health were, and I did contact the guy that evening, and he he was delighted I'd done lots of his work for them, and it was like I was gonna say sorry, but is that a normal thing that we're all meant to do?

SPEAKER_01 27:08

Okay. It's like this is failing as well.

SPEAKER_05 27:12

Yeah, well, I mean the reason I thought that it was worthwhile doing was because up until now, because our public health response has been so good, they've been so good at contact tracing and locking it down to trying to control it. I thought because I'd had this r run of cases that and one of whom had a lot of potential risk contacts. I thought if we if we get on if we don't get on ahead of this now, then we might actually lose control.

SPEAKER_01 27:37

Yeah, yeah. No, fair enough. Okay, okay. I was like, God, no wonder you're up to the crack of dawn and when do you sleep? And I have so many questions. You have a family? Are they okay? He doesn't sleep, yeah.

SPEAKER_05 27:48

But yeah, so so the yeah, so the the point is that it's it it can be controlled by uh by um recognizing the symptoms, identifying and getting tested quickly, getting vaccinated, uh uh complying with contact tracing and and um lockdown or but uh sort of no what's the word on the isolation. Isolation isolation, right? Um and uh uh you know, and so and because of that we can hopefully get on top of that and control it. Like you say now, though, it is spreading outside that population, and it's so it's spreading into a population that aren't aware of it. Yeah, and aren't aren't necessarily getting vaccinated and getting tested.

SPEAKER_01 28:28

Yeah, yeah. I even had a few conversations um with a few sex workers last night who had no idea what it was. And that's like because I thought maybe that this the you know the topic would also travel like you know, among sex workers in the community, but they had no idea what MPOX was. I was giving them a full breakdown of what it was. Yeah.

SPEAKER_03 28:47

Well, I guess like we've obviously talked about the history and the fact that you're contacting public health on a Saturday and the urgency of that on a weekend. Why is it a big deal? Like, why is MPOX a big deal and we need to like actually be acting this quickly?

SPEAKER_05 29:01

Well, there's a couple of couple of reasons for that. So, one, it's not it's not a harmless virus, and so it's quite an uncomfortable virus. Uh you know, the the vaccine gives you sort of not nearly if you have two a month apart, that it you g it gives you close to 90% protection, but you can still catch it. And uh yeah, but you do tend to catch have a much less significant illness if if you have the vaccine. And then also obviously, you know, 90% of people that get the vaccine don't catch it.

SPEAKER_03 29:28

How good are vaccines? We love vaccines.

SPEAKER_05 29:32

But if you catch it, and if you're immunosuppressed or uh elderly or very young, or if you catch it in the wrong spots, it can be quite serious. And in a not in a in the Western world less so, but in the developed world, you know, it since 2022 there's been 450, 460 deaths from the Clay 2 empox, right? Through just like how what so usually usually it'll be somebody either children, people uh children under seven, pregnant women, or immuno people who are immunosuppressed. But there have been some awful other cases of not that they're not awful, they're awful cases too. But there have been some there were two young um uh gay Spanish men who are fit and healthy and had no other medical illnesses and that they died. So it's so there is potential for it to be a very harmful virus.

SPEAKER_06 30:19

Yeah.

SPEAKER_05 30:19

Um and then you know, you know, on uh the vast majority of people who catch it, it's uncomfortable that you don't need to get the actual antiviral. There is an antiviral treatment that's held on reserve by the federal government. Oh we have some in WA. You have to go through infectious diseases. I uh this may be dated, but as far as I'm aware, we've only ever used it once with somebody who had lesions in their eye. So they had corneal infections, right? Um, but it's it there it is it is there. The it's called Tpox, right? It it there is an anti-viron. No idea. Neither. Um and uh but but the but uh other than that, it's uncomfortable.

SPEAKER_03 30:55

Yeah, and it's contact it's like quite easily transmissible.

SPEAKER_05 30:58

It's easily transmissible.

SPEAKER_01 31:00

Yeah, that's what my friend said that had it in Europe. In fact, he was like Yeah, just said it was so painful.

SPEAKER_05 31:07

And our patients tend to catch the the catch get the lesions at the site of uh of inoculation. So they either get them in their mouth, in their urethra, in the rectum.

SPEAKER_03 31:16

So just leaning on you've you've mentioned lesions, obviously. So for our listeners, what should they be looking out for to then go and prompt getting review or testing?

SPEAKER_05 31:25

So initially it's it's you've got to think of f fever. Well, so first sex within the last three weeks.

SPEAKER_00 31:31

Yeah. Fever, what's that? I don't know, it's been a long time.

SPEAKER_05 31:36

Yeah, sex for the last three weeks, fever, and then a rash, right? Okay. And the rash, the like the classic rash when you look at the pictures and read the books, it doesn't always present that way, particularly in somebody who's been vaccinated, even partially vaccinated, right? So the rash may start as a little tiny red, slightly itchy, sometimes a little bit uncomfortable sort of spots. They tend to start centrally in your face and move out. But with like I say, with our patients, often actually around the site of inoculation, right? And uh and then they they can get a um before that, sorry, they can get a pro viral prodrome, so like a flu-like illness, right? Which can be quite severe, or can again with our vaccinated patients, can be quite mild, right? And then within a few days of that, four to seven days, they're gonna start getting the spots, and then the spots evolve. So they might start looking fairly innocuous, little red spots until eventually you're looking at it going, that's not fucking normal. So that it's gone from a little uh a you know what we call medically a you know a papillomacule, yeah. So, yeah. So it basically ends up looking like uh you know what the probably w what lay people see, if they ever saw a molluscum contagious, which is a pox virus, right? Yeah, yeah. It's a sort of dome shape, it can be flu at vesicle first, and then this then it turns into this solid dole dome shape with a like a volcanic sort of umbilicus at the at the at the in the middle of it.

SPEAKER_03 32:58

It's interesting though, because like if you had herpes, like known herpes, you might have an outbreak. And maybe you you think it's just an outbreak and you don't get tested because it looks like with the flu-like symptoms and that's it. Yeah, and the you know, it's so hard to know. So I guess like if you if you do have these sorts of symptoms, just get tested anyway, even if you think it's herpes or something else, like or molluscum or something, it's just important to access the testing because we want to make sure that it's the right thing.

SPEAKER_05 33:25

Yeah, and I and and you know, you can go to any GP, but you might be better off with this sort of thing too. Yeah. Not not just because of you, but also in fairness to the GP and the GP practice, because of the infectious control infection control and not every GP can know everything about everything. Unless it's you, of course. Right. No.

SPEAKER_03 33:41

Naturally. Naturally, of course. Yeah. Um how does it feel to be better than everyone?

SPEAKER_01 33:47

Pretel Ferguson. Pretel.

SPEAKER_03 33:50

Pretel Ferguson. I was calling Ferguson. Ellie's been calling you Ferguson this whole time.

SPEAKER_01 33:55

I don't know why.

SPEAKER_03 33:56

I'm gonna call you Ferguson.

SPEAKER_01 33:57

Because in my head, I was like Ferguson. Ferguson, which I think is a Scandinavian surname. Wouldn't you be pissed if I call you Ferguson?

SPEAKER_05 34:04

Yes, Beryl.

SPEAKER_03 34:04

Great. Ferguson it is. Ferguson it is. Anyway, we digress, we digress. Sorry, not all GPs know everything, sorry.

SPEAKER_05 34:11

Yeah, so it so if possible, if uh if you're close to a specialist GP service like the Sexual Health GP services in this in in Perth or the sexual health clinics, then call ahead, tell them your symptoms, tell them you think you might have MPOPs, and they'll tell you what to do from the side.

SPEAKER_01 34:28

Yeah, they can manage appropriately and know yeah, yeah, yeah.

SPEAKER_05 34:30

And if you do go into your GP and you feel that your GP is not fully aware, then just tell them. Hug everyone in there.

SPEAKER_01 34:36

Yeah, hug everyone.

SPEAKER_05 34:38

Get naked, rub your skin, take your shirt off, and I mean again, i th interestingly for that in another one of my stories, I suppose. Yeah, yeah. So w when I was a speech pathologist, I used to work with people with laringectomies, and they, you know, they'd have a little st uh tracheostomy, and you'd I'd put in these little talking valves called blumpsinger valves, and when you put them in, they'd often cough. So I spent most of my career getting absolutely covered in sputum, right? Lovely stunning. But but since then I've never had a patient walk up to me and cough or sneeze sputum all over me until recently, right? When when this young man who's like and I'm if you are listening, I forgive you, I forgive you fully. It was a complete it was a complete mistake. Walked into my room and literally sneezed full on all over me. And it was very apologetic, but I just it just went all over me, right? They're allergic to you, and and and then you know I said, Don't worry about it, washed it off. He sat down, he was all very apologetic, and then he told told me why he came in, and it was very obvious very quickly that it was probably an empoxie. Yes, and that we hadn't triaged it properly. And when I saw the lesions, I immediately knew it was MPOX. And when he tested him, he tested positive for MPOX, including his nasopharyngeal swab. So he had virus in his nasopharynx, right? But I didn't catch anything.

SPEAKER_01 35:52

And you're fully vaccinated. I am vaccinated.

SPEAKER_05 35:54

I am vaccinated back in 2022, but at the same time, too, it's not easy to catch that way. Okay. And if you think about the 180,000 cases or more around the world, very few of them are not skin-to-skin sexual contact, very few of them are close contacts in the house, in the house, or occupational contacts. Very few. There are a couple, but very few. Okay, okay.

SPEAKER_03 36:15

So just to just to summarize, um the main transmission is skin-to-skin contact. It's highly transmissible. It can make you really, really sick, and it can be really painful, and it can spread quite easily. It has these lesions that often start with this viral sort of prodrome. You might have respiratory symptoms. It's easier to transmit skin to skin, but not through the respiratory droplets that you've mentioned. Not as easy, yeah. Not as easy. And if you have a lesion, get tested. Just do as you're told. Absolutely, yeah, absolutely. Right?

SPEAKER_01 36:47

Is that not common to spread it? It is common to through skin to skin, but not through respiratory.

SPEAKER_05 36:54

That's right. And if and and if you haven't got symptoms, get vaccinated.

SPEAKER_03 36:58

Yeah, yeah. Yeah, so let's talk about that then. So um tell us a bit about so obviously this this episode is is sort of about MSM um or men who have sex with men, and tell us a bit about um so my understanding is the vaccinations initially were uh targeted for this population. Can you tell us why originally and and what's happening now? And and what is the vaccine and who can access it and that sort of thing.

SPEAKER_05 37:20

So it's a third generation smallpox vaccine, Janios, right? So it wasn't designed against Mpox, it was designed against smallpox. It was w uh we in in interestingly, I didn't know any of this until I was a part of this whole process. But Janios is a it's a third generation vaccine for smallpox. It's a live attenuated vaccine, so it means it is the it is actually a a variation on the virus itself that's been uh genetically neutered so it can't replicate. So you can give it to people who are immunosuppressed, it's not contra-indicated like a lot of the live vaccines are for people who are immunosuppressed. It's not, it's very cool. It's which is very cool, very cool. So we so you can give it to so for instance in our HIV pop positive population that are more at risk of epoxy and and or somebody who's on chemo or on you know, autoimmune condition, and they've got they've got they've got a treatment for the rheumatoid arthritis or whatever, you can use it. Yeah, yeah, yeah. Use it. And actually they should they're the people who should use it. Absolutely. Um it's one one two vaccines one month apart. Um it's very well tolerated. They so we only got a a certain and Australia was successful at a tr at at getting a certain number, but because there was only a l a limited number, we had to do two things. One was try and focus on the highest risk group. So at that at that space, at that time it was uh people who had men who had sex with men who were highly sexually active. Yeah right. Um and then also the other interesting thing at the time, if you give the vaccine as a bleb, as a little bleb, a little bit like the older the older listeners out there will remember the original smallpox vaccine where they've created a scar in the and and it was very unpleasant, right? That you you only need one-fifth of the vaccine to be able to get a good immunological response. So you're gonna get it, you're gonna raise a much better immunological response from a vaccine if you give it intradermali. Intradermali. The reason why we don't do that though is because nobody will take the vaccine because it's an unpleasant way of getting the vaccine, can leave you with a scar, and so it's not it's not socially acceptable or pub acceptable to the public. But at the time, and again, another reflection of this population, no problem. Yeah, yeah, yeah. And even though, like, you know, the stereotype would be, oh, you know, a young gay man doesn't want to be left with a mark or some sort of stigma, some sort of and and that was actually important because obviously some men who weren't out, if they had that mark on their arm, right, it could be a sign that's so that they've had the MPOX vaccine, right? So we we had to be cognizant of that and and give it in places that they that it wasn't as obvious. Yes, please. And and again, I suppose it's also what you're used to.

SPEAKER_01 39:56

Yeah, true.

SPEAKER_05 39:56

Yeah, yeah. So it meant that we had a very finite amount of vaccine, but we had five times more than we had because we could use five doses for every one dose, right? Which was really good. It was good. And then eventually when the and when we got enough vaccine, then we've moved back to to you giving it subcuts. Yes. Like leave straight into your arm with your tent tend to. I think at the moment we've got in WA we've got 18,000 vaccines, so it's stunning. So it's which is great, but it's still not like MPOX is, you know, we've now got a couple of cases that are outside that classic population. The MSM population. MSM population. So we've now, you know, we've got a couple of heterosexual men and a couple of heterosexual women. And so we've got to be very again focused on where we because we could get rid of we could 18,000 vaccines won't go very far now. True.

SPEAKER_03 40:45

So so so originally we were vaccinating or targeting, I suppose, not in like a punitive way, but um the MSM population for the case. Targeting non-derogatory. Non-derogatory, just amazing. Um the MSM population. Um and you've mentioned it's two different, it's the same vaccine at two different times, one at one day and then one after 28 days. It was just a bleb under the skin, but now it's sort of in the subcut. Um what is happening now with vaccination? So obviously it was targeted at this population. Are we now offering it to everyone? Like who who can access this vaccine?

SPEAKER_05 41:19

Yeah, it's a good question. So the the the uh the guideline is still the same, but actually anybody who goes anybody who has multiple partners might have partners who who are very fluid or might go to sex on premises sites or sex parties. I mean, realistically for me, if somebody came and said, look, I've I've got I'm very sexually active, uh if they wanted it, I'd like to.

SPEAKER_01 41:38

Yeah, even people like we've been advertising for anyone who sort of is on the app using to have casual sex, that you know, yeah, that as well. Yeah, yeah. Okay. Yeah, interesting.

SPEAKER_03 41:49

Okay. So you mentioned that there was a treatment, Tpox. Yes. In what circumstances would these treatments be given? And like, say if I was somebody that I had MPOX and I was like, oh, I'm really quite unwell, can I have this medication? What would mean that I could have it?

SPEAKER_05 42:05

Okay, so yeah, well that that would have to be got that would have to go through uh infectious diseases. So that would have to go through an infectious disease consultant in one of our major tertiary hospitals, right? So you'd have to be referred in and then they would assess them on their criteria. Um uh my understanding of that would be that you'd you'd have to be potentially uh very unwell. So you'd have to either be immunosuppressed or at risk of pneumonitis or a meningitis. So that's a chest infection or a brain infection. A chest or a brain infection. Yeah, yeah. Um you know, and that that's uh at the that's rare.

SPEAKER_01 42:40

Yes, it is treatment for empox.

SPEAKER_03 42:42

Yeah, so so basically, you know, if you're listening and you have empox, it's okay. It's okay. Like we can just calm down. You know, it does everyone calm down. Okay, it's a big it's a big fucking deal. We just calm down. You you you may get really sick, but you may not, right? And if you get really sick, don't panic. There's services and treatments available, is what we're trying to say, right? So not everyone can access the treatment, but if you need it, you can get it.

SPEAKER_01 43:05

Can I just clarify that um so someone's just been diagnosed with MPOX, they're told to isolate, and are they is it just that they just sort of wait it out, or is there actually Yeah, what is it? You know, is there anything they can do? Obviously, you said to go through infectious diseases if it's getting really serious, but usually is it just one of those things you just have to write out. Yeah, so what but so that's what I was gonna say.

SPEAKER_05 43:27

So what we what's right. So what we what we're doing.

SPEAKER_03 43:30

Don't be so mad, Ferguson. Calm down. Sorry, Ferguson. He's so mad at you. Look at his face, he's so mad at you. God never sleep again.

SPEAKER_04 43:41

Yeah, you could do that okay.

SPEAKER_05 43:43

Yeah, so if if uh that's why one of the reasons why it's probably a good idea to go to a uh either one of the uh sexual health GP services or the sexual health clinics because they they will give they will offer you support then, right? So it's the public health are fantastic, the public health nurses will call. You constantly or text in and make sure you're okay. Shout out to Medicine. But they will also have to public health asks. Yeah, they're great. They will also ask if who you've got what medical support you have. And somebody will call, usually well, it depends. If somebody at 11 p.m.

SPEAKER_00 44:17

at night. How are your steamworks?

SPEAKER_03 44:19

Fergus will call from steamworks.

SPEAKER_05 44:23

And then it's symptomatic control, right? So if they've got uh the proctitus, which is the lesions in your bum, and very, very s can be very sore, then giving them pain relief and and local anesthetic ointments can be really, really important, right?

SPEAKER_01 44:37

Wonderful, yeah.

SPEAKER_05 44:38

Yeah, so same thing if they've got them in the mouth. So it's basically symptomatic control. Cool.

SPEAKER_01 44:43

That's yeah, that's what I and you probably already had that down. I was just gonna ask about yeah, management of of of the pain and symptom control. Yeah, so just to summarize, please summarize the S in Shaman's downs for summarize. She's so good at it.

SPEAKER_03 45:00

So Mpox is a virus. Um, it's part of the smallpox family. Um, it's transmitted through skin-to-skin contact, initially predominantly through the MSM population, but it's now spreading due to differences in sexual preferences and sexual activity. It can present with this flu-like illness and a rash that's like little vesicles with a little um umbilication in the middle. Um, and you can get really, really sick, or you cannot get sick at all. Um and if you're not sure, get tested. And the way we test for it, which we actually didn't talk about is the way we test for it, I suppose, is we take the little dry swab of the area. No? Um and we don't do blood tests for empox, but we certainly do the little swabs. If you've if you've got uh possible empox, we swab everyone, throat, and azopharyngeal.

SPEAKER_05 45:47

Which is basically like a COVID swab. It is like a COVID swab, yeah, yeah. Okay.

SPEAKER_01 45:50

And then So just yeah, even if someone yeah, no symptoms in the nose and mouth, we but we swab still do it everywhere.

SPEAKER_05 45:56

Because public health will want to know in terms of their infection control. Yeah, yeah.

SPEAKER_03 46:02

Um and then once you've had a confirmed diagnosis, you do have to isolate. Um but public health will guide you through that. So don't panic. Well you'll get given guidance and public health will contact you regularly. Um treatment is supportive, okay, so pain management um largely, okay. And if you've got an excellent GP like Fergus, he'll just follow you up personally. Um and if you're really, really sick, there are potential treatments available. You can prevent severity of illness potentially with this vaccination that uh originally was in the MSM population, but now we look at other high-risk groups. Um and it's subcut. Yes. Um two doses, one and then one 28 days apart, really well tolerated.

SPEAKER_01 46:48

In terms of vaccination, I always say to my clients, yeah, as far as vaccinations go, it's a really chill one. It's a chill one.

SPEAKER_03 46:54

I got a lump after because I also got it, but I got a lump and then like a fucking idiot, I went boxing. And everyone's like, why'd you do that? And just like spread down my arm, like anyway, whatever. Um but yeah, so it's it's actually a pretty good scene. You know, it's chill.

SPEAKER_01 47:08

In terms of side effects, in terms of all the things that we're gonna do.

SPEAKER_03 47:10

Yeah, and like some of our listeners might be wondering the cost of all this, you know, cost of living crisis, I suppose. Um, you know, if you're going to a GP, they might bill you according to to standard billing. If you go to a sexual health clinic or a public hospital, it might be free. The vaccine is largely free. In fact, it is the vaccine is free. The vaccine is free.

SPEAKER_05 47:27

They can't charge it for the free. Yeah, they can't charge it.

SPEAKER_03 47:29

So don't panic, you can get free vaccination without vaccinations. Yeah. Is there anything pertinent I've missed with MPOX?

SPEAKER_05 47:36

We put you probably just mentioned in your absolutely excellent summary.

SPEAKER_03 47:40

Thank you so much. Contact tracing. That's the nicest thing he's ever said to me. I believe it.

SPEAKER_05 47:45

And uh uh, you know, that to it to participate in and be as as comprehensive as you can with public health or the or the patient who person who's diagnosed you with the contact tracing. Yeah, so it's a integral part of controlling.

SPEAKER_03 48:00

Absolutely. So it's a team effort, guys. It's a team effort. No need to be ashamed. No. Okay, everybody has sex, no biggie.

SPEAKER_05 48:06

Yeah, and nobody nobody's gonna out anyone, you're not gonna be mentioned.

SPEAKER_03 48:10

No, it's all very anonymous. They're just kind of doing their job to protect you and the community. Yeah, absolutely. Yeah, absolutely. Okay, so now I just wanted to talk a little bit about PrEP. So HIV PrEP or pre-exposure prophylaxis is the use of antiviral medication to help prevent sexual transmission of HIV infection. Can you tell us how PrEP was discovered?

SPEAKER_05 48:47

Oh, yeah. Oh, interesting. So PrEP has got two there's one tablet with two drugs in it, Tenofavir and M-tracitabine. Fancy names for antiretrovirals that we've used for decades to treat HIV as the sort of backbone of a three-drug regime, right? So a partner, a third drug in there, right? Um, and really, the I mean, the original historic um c uh reason behind PrEP was it evolved from PEP, it evolved from post-exposure prophylaxis. And that happens. So if you look at if you look at the data looking at HIV uh deaths from HIV or AIDS-related deaths in the Western world, unfortunately, this is not true in the developing world, but in the Western world, you look at a sc uh uh graph of that, and it's going climbing, climbing, climbing until 1996, and then it falls off a cliff in 1996. It's just literally like a pyramid peak and just drops. In a good way. Like a cliff that you want to fall off. That's exactly what you're doing. Yeah, okay. So the the death rate from HIV in the in the Western world, in in modern health systems, plummets, right? And that's with the with the uh introduction of highly active antiretrovirals. In other words, when they they had more drugs than two to attack the virus from more than two angles, so that even if it was it was uh replicating so fast, it couldn't mutate quick enough to to counter those drugs, right? So th those drugs were highly effective at pr at keeping people alive, they were fucking awful drugs. Dreadful, dreadful side effects. There were, you know, there were patients at the time, you had patients that were taking handfuls, fistfuls of medications every day. But at the same time, very quickly, if somebody like me who was treating a patient with HIV who had an AIDS-related illness and then was given this these new uh highly antiretroviral drugs and their viral load dropped and they started to get well again, but I was taking a lesion off them or sat on their bed and sat in a needle or got a needle stick injury, there were little individual reports in the literature of some of medics saying I got exposed to a patient who's got uh who's on antiretrovirals and HIV, and I thought, bugger it, I'm taking his medication, and I've taken them for a month and I'm HIV negative, right? So the original PEP stuff was individual case studies reported uh following occupational exposure. Oh, that's so interesting. And then somebody clever went, we should study that. Yes, and put that in a structured way, and so that evolved into occupational HIV exposure, post-exposure prophylaxis. So that if you if you took antiretrovirals within 72 hours of the exposure, took them for 28 days, it was highly effective. Right. So that that's where the post-exposure prophylaxis studies came from.

SPEAKER_01 51:33

Get out just healthcare professionals. Blumsy, thieving healthcare professionals, I love it.

SPEAKER_05 51:39

And so then clever people go, let's research that. Yeah, and then from the post-exposure prophylaxis uh uh studies for occupational studies, the next evolution for that was what if we gave this to a gay man who came in and said the condom broke, or what if you gave it to uh an MSM who who came in and said, I've just had sex with somebody, and his partner's just sent me a message to say he's HIV positive and not on antiretrovirals, or an intravenous drug user who shared but but came in and we got to them within 72 hours. Interesting. And so that was then the next evolution of post-exposure prophylaxis research that if you had a patient who was compliant and took the antiretrovirals within 72 hours of exposure and took them for 28 days, it's highly effective. More effective depending on the group and depending on how compliant they are. Yes.

SPEAKER_01 52:28

So the PEP game the PEP came before the PrEP. Yeah.

SPEAKER_05 52:32

So then so the next clever person goes, what if we had a population who's got a background level over a certain percent, so one, two percent risk all the time. If we gave it to them before and after, will it protect them? And who was that population? That was the that was an MSM population, right? Yes. But there was also it it it coincided with it was MSM and intravenous drug users. Yeah. The the again the the compliance issue with inter intravenous drug users because they're not nest because their life is a lot more comp more chaotic. The the efficacy was less. But in the MSM population, who like we've talked about earlier, are incredibly compliant and educated and very motivated uh to to counter the HIV epidemic at the time, which was which was like a war. So so the those prep studies were that's how it evolved, right? So basically it's you're getting you're giving two antiretroviral drugs, so two drugs that are all in one tablet, so it's one tablet with two medications in it, that we've used for 30 or 40 years to treat HIV with a partner drug, right? So we know an awful lot about them. And the way you gotta think about it is a window. If you've if you've taken enough of the drug to get the level high enough to inhibit the integration of the virus, particularly in your rectal mucosa, right? And remember this is MSM. And that's the highest risk. Right, that's right, and that's the highest risk. This is not, I'm not talking about women or cisgender women, right? This is MSM or trans uh women, right? That's that's if you take enough, if you take a high a loading dose and uh uh uh far enough away from the exposure that the level of the drug gets high enough, and then you take another medication afterwards and another one afterwards, and I'll tell you what that means in a second, right? Yes, right, then you're gonna you're gonna stay in that window to protect you from the integration of the virus. So so that's where when I'm teaching people at prep, I tell them that they've got to remember two sets of numbers two, one, one, and one for twenty eight days if you fuck up. Yes, okay. And that's it. That's it, right? So you start you start with two, you finish with one one. The two stands for two tablets as a loading dose and wait at least two hours. Yep. That's the two before the encounter.

SPEAKER_03 54:40

And just to clarify, encounter, right? So you've just identified that anal mucosa or bottoming or receiving is the highest risk. Are there other ways? Like, should what is what is a high risk encounter for someone to be like, oh, I I could take prep.

SPEAKER_05 54:55

Yeah, so so interesting. Like early on we had criteria, and so we had we had criteria where you had to sort of qualify for a high enough risk, right? And so that would have been, you know, if you were if you were bottoming, if you're having receptive anal sex, that was the highest risk. If you were topping without a condom, that did meet the risk. It was a lower risk, but it did meet the risk. There's no risk with oral sex, you don't need prep with oral sex, right? Uh and I mean there's there's a couple of potentially reported cases, but there's absolutely no evidence that I'm aware of that there's ever been a transmission of HIV orally.

SPEAKER_00 55:28

Really? Oh, I didn't know that.

SPEAKER_05 55:30

I didn't know that my understanding, I'm I'm open to being questioned on that uh because I haven't looked at it with a lot of people. He loves being challenged everyone said. My understanding on that is that there are that in any cases where it's been reported, there are other variables that could be possible. Yes. Right?

SPEAKER_01 55:45

I had someone call who, after a like, I guess a sort of cum dump party, I can I imagine, fell asleep with lollies in their mouth and then like said that they caused some sort of ulcer in their in their mouth and was worried about HIV transmission through that wound, I guess, that was in the mouth through oral. Is that a thing? Or if someone has a ulcer in their mouth, does that increase your risk?

SPEAKER_05 56:07

No, I mean it's risk of syphilis, definitely. Oh, there's always risk of syphilis.

SPEAKER_03 56:12

Stub toast syphilis.

SPEAKER_05 56:14

Risk of chlamydia, risk of gonorrhea. Yeah, yeah, yeah, yeah. But the risk for HIV is negligible. Absolutely negligible. So if somebody was to come to me, for instance, and ask for for PEP for post-exposure prophylaxis for that. And I I'm I'm happy to give it because I would hate to send somebody out with the anxiety that they might go with that. Because there's a lot of HIV anxiety. But like, you know, there's a there's a leading HIV physician in in Sydney who would say give them volume because that's just as effective. Honestly, truly. Because it's more you're treating treating the anxiety rather than. Now the guidelines have all changed. So that HIV anxiety is a legitimate reason to give prep. And if you think about it, if you're a young gay man or if you're a young man who has sex with men or occasionally goes out and has oral sex with men, but is very, very fearful of that, who's who you're you're entitled to have a sex life, free of that anxiety. Honestly. For a drug that we know is highly effective and very safe to take. It's safe.

SPEAKER_01 57:12

Yeah, yeah, yeah. Yeah, I get again, Shamani, you talk about this all the time about like risk outweighs. Benefits benefits. Yeah, yeah, yeah. And like from being on the helpline, you know, Australia-wide helpline we hear about this, this the HIV anxiety, you know, a lot. It's it's there.

SPEAKER_03 57:28

All right, yeah, and the benefit outweighs the risk in that moment. Absolutely. Yeah, yeah, yeah. That is really what medicine is, right? Risk versus benefits. Yeah, yeah. There's no definitives.

SPEAKER_05 57:38

Absolutely. Absolutely. So I mean it's funny, you know, I I often uh could be at a forum with doctors where we're talking about this sort of stuff, and somebody goes, are you not encouraging this behavior?

SPEAKER_04 57:50

Yeah, right?

SPEAKER_05 57:51

So that you know, all these people on prep, they're not using condoms anymore, right? And I go, so just I just clarify, when somebody comes into you who's had a coronary stent and has got high cholesterol and they tell you that they've had a cheeseburger, do you say, give me your fucking statin back and get out of my room?

unknown 58:05

Yeah.

SPEAKER_00 58:05

Thousand percent. All we do it's harm reduction. People live their own lives, right?

SPEAKER_03 58:12

Like it's the that takes the paternalism out of it all.

SPEAKER_05 58:26

So anyway, so getting back to so prep, if you take a loading dose of two tablets, wait at least two hours, not more than 24 hours. So that window, now that means that it takes two hours to get the the level of the drug up to a level in your rectal mucosa specifically, that will protect you.

SPEAKER_01 58:42

And so it just confirms this is prep. This is on demand. HIV prep on-demand, event-based prep, right?

SPEAKER_05 58:47

Yeah. Although, you know what? So again, this is part of the sort of story, right? With the what we've done along with that history that was talking about, that sexual health history, you assess their risk, and then you're supposed to advise whether they should be on daily prep or on-demand prep. And actually, in real life, no one person always fits that risk all the time. People's sexual habits and risk change all the time. So you have to equip them how to change, you have to tell them, you have to let them know how to start and how to stop, how to go from on-demand to daily and vice versa. Because otherwise, they'll just do it anyway, and they'll do it, they'll work it out amongst themselves or within.

SPEAKER_03 59:21

And often and often I have patients that, you know, when I'm doing follow-ups, they'll say, Oh, just remind me how you take it. Exactly right. You know, just remind me how you take it. Brilliant. And they'll and they'll be like, Oh, I just do two two hours before, and then I just do one. And I was like, Where did that come from? And they're like, Oh, oh, I just thought, or I'll do it three or four days after. I was like, Where did that come from? And so, like, where are these information coming from? It's because they were daily and then they their sexual activity sort of decreased and they were trying to do like on demand like per occasion. So you're just kind of re-educating over time.

SPEAKER_01 59:51

So yeah, there's two ways to take prep daily or on-demand, and we're we we're talking about on demand, right? Yeah, we're talking about on-demand. Event-based. And then event-based, yeah. So two tablets at minimum two hours before an encounter, and then one tablet for one tablet a day for the two days after, two one one. Is that what you mean? So you've done that for that encounter. So you've had the two, you've had the encounter, then you've had the one-one, and then you've had another encounter. And then is it two one one again?

SPEAKER_05 1:00:22

So it depends when the an the next encounter is. Right? So i so basically if you're if that next encounter when was you tell me when the next encounter was.

SPEAKER_01 1:00:31

Okay, so say that someone Okay, okay, it's a Friday. So Friday morning, someone had two, and then they had the encounter Friday night, and then they had a tablet Saturday, tablet Sunday, they had another encounter on the Monday. Are they still covered from what they've had?

SPEAKER_05 1:00:47

They keep on daily. They keep taking a tablet every day, right?

SPEAKER_03 1:00:50

As long as you finish it two days after the last encounter. So just keep going until then. So you finish with one one.

SPEAKER_01 1:00:57

I've got it.

SPEAKER_03 1:00:57

You finish, you always finish with one one. Yeah. So I usually just say like at least two hours before. And then I don't say it's not per encounter either. It's just uh, you know, each each encounter. But as long as you finish two days after that lasting, just keep taking it until two days after and then stop.

SPEAKER_01 1:01:15

Okay, that's so helpful. Yeah. I really feel bad about the advice I gave my friends.

SPEAKER_03 1:01:18

Yeah, they just go on down, they keep going. As long as it's always two days after.

unknown 1:01:22

Yeah.

SPEAKER_01 1:01:23

I should have said that to my friend who was going to Europe like a few years ago.

SPEAKER_05 1:01:26

So you start with two, you take a tablet every day, mum comes to visit, you you're you're putting it away for a while, you take a tablet the next day and the next day, and you stop. Still two one one. Still two one one. But everything in the middle is daily.

SPEAKER_01 1:01:37

Yeah. Oh, I did not know this.

SPEAKER_03 1:01:38

Yeah, yeah, yeah. So that that's I think that's what Fergus is explaining in terms of the flexibility, right? Like so you don't fit a certain sexual profile. Like, I wish I could just say, yes, I have a sexual partner every single day.

SPEAKER_05 1:01:49

But you know, 60 days. And if you and if you're on if you're taking it on demand and you don't uh predict that you're gonna have sex and you're in connections, you have a few drinks and you end up having sex without taking the loading dose.

SPEAKER_01 1:02:02

Because that's what uh the other thing is at home.

SPEAKER_05 1:02:04

And you but as long as you do this within 72 hours, you go home, take your ta take your prep tablets out, take your tablet every day for 28 days, and that's prep as PEP. Yeah. That's two drug PEP, right? Post-exposure prophylaxis, which is nearly always okay in Australia.

SPEAKER_03 1:02:18

Yes. Yeah, yes. And then you get tested. Always come in for testing.

SPEAKER_05 1:02:20

And then yeah, and then you come in and have that conversation. Yeah.

SPEAKER_03 1:02:23

So it's actually like a really good drug to like you can use it as long as the patient's educated, right, in order how to take it based on their sexual activity.

SPEAKER_05 1:02:31

If you're taking on-demand prep and you do two-one one around an event, right? But then you have another event within a week, you don't actually have to do two-one one, you just do one-one one. But that just confuses. If you take an extra one and do two one one, who gives you shit? You're just gonna remember it easier. Yeah, yeah, yeah. Yeah, totally.

SPEAKER_03 1:02:48

So you just say two one one, two-one one, two-one one, always.

SPEAKER_01 1:02:51

Okay, yeah, two-one one, always clarifying.

SPEAKER_03 1:03:00

So um HIV PrEP stands for pre-exposure prophylaxis to prevent against HIV infection that's sexually transmitted. It's the use of an antiretroviral medication that historically has been used to treat HIV, which was discovered by healthcare professionals sitting on needles. That's what that's what I've got. And they just tried it and then the the data was extrapolated, and now we have this highly effective drug.

SPEAKER_05 1:03:25

Well, so proper studies, right? Proper studies, yeah, okay, fine. Yeah, and it's always started somewhere, right?

SPEAKER_03 1:03:29

Now we've got proper studies, and it's like a highly validated drug, very evidence-based. So don't worry about that, guys. It's well studied, it's safe. Um and there's two ways to take it based on um w what we generally uh ascertain is the predictability of sexual encounters and the frequency of which you're having sex. So if you can predict your encounters and sort of semi-infrequent at a period of time in your life, you might take the 211. So that's two tablets, at least two hours before the encounter, and then one tablet for two days after that. Okay? Or if you're like, actually, I'm gonna fuck a lot of people coming up, um, you might take it daily, right? And so then you just take it daily, and as long as you finish two days after the last last encounter, we're all sweet.

SPEAKER_05 1:04:12

You've also started with two though, right?

SPEAKER_03 1:04:14

Yes, you've also started with two, correct. So two, and then you take it every day, and then you stop at least two days after that.

SPEAKER_01 1:04:19

And that's as long as you finish. Two days after. Two days after. Always two days after. Two days after. As in finish the tablets, not finish, it's how that's fine. It's admirable. Admirable.

SPEAKER_03 1:04:29

Um and then you can, if you you know, we we're all humans, sometimes we might miss our prep. That's totally fine. If you have an at-risk encounter, um, which we established was predominantly through anal mucosa, then you might take it as PEP, so post-exposure prophylaxis, where you take one tablet every day for 28 days and just come in for testing. Absolutely.

SPEAKER_05 1:04:50

Or the other the other scenario that's actually quite common where somebody takes two tablets as a loading dose but actually has sex within the hour or an hour or within the two hours. And then you say, okay, just take it daily for 28 days. Yeah, okay.

SPEAKER_01 1:05:02

Okay, that's a good point. Roll on. It's a ro it's like a roll-on. It's roll on. You know, as in like a you know when you like sign up to something, can you get credits and they're that have a rollover effect? It's kind of a rollover effect, isn't it? It's like okay, yeah. Okay, so um and you've said like obviously with the anal mucosa and rahda rahda. Yeah. But also, what about people if they're having like quite a lot of sex overseas or in Asia? Is that also something that we look out for? Yeah, absolutely.

SPEAKER_03 1:05:29

Yeah, we do, we do. We certainly will look at risk profile overseas, and you know, we we it's part of our sexual history taking, right? We the are the planning to have sex interstate, overseas, where, where have you returned from, that sort of stuff is all part of um uh yeah.

SPEAKER_05 1:05:44

And again, that's that's the reason why it's important to teach people how to start and stop. So if you've got if you've only taught somebody how to do on demand, but then they're going on a holiday, right? Then how do they know how to change to swap over to daily? And then when they come back from their holiday and they want to go back onto on demand, how do they? No to change back to what I or you know, my one the West Australian addition to this is FIFO prep.

SPEAKER_01 1:06:06

Yes. Oh my God.

SPEAKER_05 1:06:08

So you know you're getting on the plane on the way back from site, you take two tablets, you take a tablet every day on the off swing, and you take a tablet for your first two days back on site. FIFO prep.

SPEAKER_03 1:06:17

Yeah, and like the the like the incredible thing about this is you're empowering the patient to make decisions for themselves, right? It's really autonomous decision making. It's like, okay, I have the power to make a decision with this tablet based on my sexual activity, and that's kind of what we're trying to do. Yeah, and we simplify it.

SPEAKER_05 1:06:33

To be able to learn it and be able to apply rules to it, we simplify it. So that actual ideal patient who's either on on-demand or daily doesn't necessarily always exist, right? Correct. People chop a change.

SPEAKER_03 1:06:43

Yeah, yeah. That's true. And you just gotta you gotta check.

SPEAKER_05 1:06:58

Can I can I just have a little message to my patients out there, and you know who you are. You guys that you know you should be on daily, stay on fucking daily.

SPEAKER_02 1:07:09

Don't even don't even question it, dolls.

SPEAKER_00 1:07:13

Just stay on it every day.

SPEAKER_03 1:07:14

Now, I guess the thing that I wanted to address is that um obviously, you know, we've mentioned that PrEP is the H type prevention, but it's nothing is 100% in medicine. Literally nothing. Okay? We all slip up, sometimes we miss doses, whatever it is. This does not preclude you from getting regular testing. That's right. Okay, so can you just run us through, I guess, um so so we know it's a highly effective drug. We we know how to take it now. What are just briefly, what are the side effects and why are we monitoring every three months essentially? Or 30 days and then every three months, yeah.

SPEAKER_05 1:07:46

So the side effects is there's often a little not always, but the people will describe it as sort of initiation syndrome where they feel l l mild sort of side effects of a little bit of tummy upset, maybe mild nausea, sometimes a headache or fatigue in the for the first seven to ten days, and then after that that passes, right? If you're taking it on demand, you may not be on it long enough for that to pass, and you may have that experience the first few times that you take it, right? Some people complain of nausea all the time, and they can they and even s fewer will find it very difficult to tolerate because of that. If that does happen, bring the bottle that you've taken that you've been given from the chemist with you back to your prep prescriber so they can see which particular generic you've been given and the particular salt that that drug is mixed in. Because they're all the same drug, but they're mixed in different salts. And then the the the prescriber can change it over to a different one. There's three of them. They can change you over. And you and sometimes you can find the version that actually you tolerate best.

SPEAKER_03 1:08:43

Yeah, so just a reminder, you don't have to tolerate the side effects. Yeah, right. You don't need to suffer anymore. You don't need to suffer any more dolls. Okay, this is unnecessary suffering dolls, okay? Just if you have a problem, bring it back.

SPEAKER_05 1:08:57

No, no, if you're having sex, you should suffer a little bit.

SPEAKER_03 1:09:00

Okay, I'm not having sex.

SPEAKER_00 1:09:04

Yeah, yeah.

SPEAKER_03 1:09:04

Sorry, sorry, continue. Yeah, yeah, yeah.

SPEAKER_05 1:09:06

And so that's the initiation syndrome. And then the long-term side effects are from the Tenofavir component. And that's from the Tenofavir in the PrEP that's available on the PBS, which is very, very cheap. I think when when when PrEP came out initially, it was $512 a bottle. That's what the government was. What?

SPEAKER_01 1:09:23

That was going to be my next question. So there was the costs.

SPEAKER_05 1:09:25

That's what the government paid for it. Which fair enough, fair play to them, right? The government paid 512 bottles for one month supply when it first came out. It's now generic, it's gone, it's out of patent, and there's lots of generic companies making it. And it's now, I think the government now paid $12 a month. Right? Which is now below the threshold of the PBS subsidized questions.

SPEAKER_03 1:09:46

We don't really have time to go into the PBS. Oh no, we don't rely on some stuff. But basically, it used to be really expensive, and now it's not.

SPEAKER_05 1:09:51

Yeah, and it's now so it's I think it's 22, 24 bucks a month, right? When you go to the right, gold.

SPEAKER_04 1:09:56

Yeah. Yeah.

SPEAKER_05 1:09:57

So so the the the tonophavir component in the drug, in that version of the drug that's under the PBS, can cause a little drop in your bone density and a little drop in your kidney function. Correct. We watch that, we test for that over every three months. You have to your kidney function has to be adequate to tolerate it, and we watch. And then all of the evidence is because that drug is now has been superseded by a better drug in the in the treatment of HIV, we've now got a huge amount of data from from HIV-positive patients who were on that drug before as treatment of the HIV and have now been transferred over to the more modern version of it. And their renal function and bone density improves over after they come off it. And there is definitely also a difference. So it's fit healthy patients on the case. It's kind of reversible, is sort of the point. Yeah.

SPEAKER_03 1:10:54

So it's like it's it's okay that you might have an impact, but but it it's it can it can reverse. Yeah.

SPEAKER_05 1:11:00

And the and the important thing too here is it's a it's a that's an impact over many, many, many years. And this is the first generation of PrEP that's about to be superseded by bigger and better stuff that don't do that. So if you're a 22-year-old going on PrEP now, you're not gonna be on this drug long enough for that for that to be.

SPEAKER_01 1:11:15

So true, so true. And look, what about sorry sorry, what about someone who did have some kidney issues, say if they had um PKD, like polycystic kidney disease. Is there an alternative? Can they start it? Yeah, what's the vibe there?

SPEAKER_05 1:11:27

Yeah, so the the newer drug that's used in HIV can be used. It's not it's licensed in Australia, it's licensed for the use of PrEP, and it's it's a newer version of Tenofavir. Okay. And it's uh it's it's uh the pro drug, so it's it's metabolized inside the cell, and it doesn't have the bone and the and the kidney effect. Amazing, right? It's it is licensed by the TGA as as for prevention of HIV, and it's uh so it's licensed uh to be used for that in Australia. It's not on the PBS because it's still not at a patent and it's a thousand one hundred dollars a bottle sort of stuff. You can get it on the PBS for HIV treatment, but not for PrEP. But you can get it legally with an Australian doctor's prescription. You can buy it overseas, and there's uh you go into the PrEP Access Now website and it'll tell you what pharmacies you can access it from. It's very cheap. Okay. And with uh an Australian doctor's prescription, you can legally import three months at a time into Australia. Okay, that's awesome. Thank you. And it doesn't do that, and then there's another drug now, there's a long acting injectable. Yeah, tell us more about that.

SPEAKER_03 1:12:29

Because I'm getting a lot of questions about the long-acting injectables.

SPEAKER_04 1:12:34

I'm so excited.

SPEAKER_03 1:12:35

Tell me more because like every time I try and talk to you about this, like you're just like whisking off to the another job that you have.

SPEAKER_05 1:12:40

So this is this is an injectable, so it's you get a loading dose a month apart, and then you get it every two months. So it's an intramuscular injection, a little bit like uh the penicillin injection that somebody might have at there might have got for syphilis, right? So a little bit uncomfortable the first few, but most people tolerate it really, really well. Um and it's it's uh called apertude is the is the drug name. Aperitude. Yes.

SPEAKER_03 1:13:03

Apertude.

SPEAKER_05 1:13:04

I don't like your apertude. I don't like your apertude. Capitagravir is the actual drug name.

SPEAKER_02 1:13:08

Oh, capital, yeah. Yeah, yeah, yeah, yeah, yeah.

SPEAKER_05 1:13:11

It's an integrace inhibitor. Fancy words. Yeah, fancy words, right? And it's highly effective. It doesn't have the issue issues with kidney functions. So there is a special access scheme. VIVE, the drug company that make it, uh made a hundred uh well, not a hundred doses, they made enough available for a hundred people to go on it. Amazing. Under a special access scheme that we had a sort of criteria and uh your patient that you've just mentioned would meet that criteria. That's so cool.

SPEAKER_01 1:13:39

That's so good. Because you know, you think, as you say, it's probably a small number of people that would meet that criteria, right? MSM with like load kidney function. But like it's nice to know that there is something there.

SPEAKER_05 1:13:49

That's also that's also and you might find that people that find it very difficult to be compliant and very difficult to take their medication, it would be very useful. It does, it does present a different problem to the services that provide that because the the how the drug then falls down in your system over a period of time. If we lose you to contact, lose you, then we need to chase you down because you need to be back on oral prep, because you there's a period of time when you're gonna have some antiviral drug in there, but it's not gonna protect you enough. Right. And we may we may then get virus that's that's resistant to that very essential form of drug. Yeah, so there's some complications that go with it. Yeah. It's it's I know you didn't want to talk about the PBS, but it it didn't work. The pharmaceutical benefits scheme, guys. Yeah, yeah, yeah. So the subsidized scheme for it did go through that process right now for our international listeners.

SPEAKER_03 1:14:37

Yes, yes. We have a lot, by the way.

SPEAKER_05 1:14:38

It did go through that scheme to the to be to the right to the very end where it was nearly accepted and then it all sort of fell down, but we're hoping that that comes back soon again. Yeah, okay.

SPEAKER_03 1:14:47

So there's particularly.

SPEAKER_05 1:14:48

So it's not available and uh subsidised here, it is available on a private script. But that would be very expensive.

SPEAKER_03 1:14:54

Okay, okay. Amazing thanks. So to summarize, um so the main side effects are tummy upset, essentially. Um, but usually those things will dissipate over a period of time. If it's on demand, you're less likely to get them. Um there are reversible impacts on kidney function and bone density. Um and you know, if we strip it right back, go back to basic general practice and holistic care, good resistance exercise, just avoiding things that affect the kidneys. You know, that's just what we want to do as well to maintain bone density and kidney function. Um it is available on the PBS. If you do have those side effects and things aren't going so great, you can talk to your doctor about accessing it online but legally, um, in a different form, essentially. But all right, the details we'll do that for you. Um and then there is this long acting version that is not available to everyone, but it is available to some people if you're interested and want to check it out, just go to your preferably sexual health clinic who may have a bit more information about it rather than you know your regular GP. Um and you should still get three-monthly testing so we can check your kidneys, make sure you don't have any other STIs, and make sure you're safe.

SPEAKER_05 1:16:06

Yeah, and the other part of that, which sorry, which you if if you're taking a drug to protect you from HIV and everyone around you is taking that drug to protect them from HIV, and it's sort of like it's not a vaccine, but it's sort of like a vaccine, right? A prevention. If you take it incorrectly or or it fails, and you're unlucky enough to contract HIV while you're on it, and then you keep taking it, you're gonna develop a strain of the virus that's resistant to which which isn't the end of the world for you because we can I'll change it up for you, the treatment up for you. But it means everyone around you is not protected from your strain of HIV.

SPEAKER_03 1:16:42

So it's just really important to get testing. Yeah. Come back.

SPEAKER_01 1:16:45

Okay, wait, wait, wait, wait, wait, so sorry. So don't say sorry. If you're so if you're on just say that again one more time, so sorry.

SPEAKER_05 1:16:53

Yeah, so if you're on prep, you're on HIV prep and you didn't take it correctly, you made a mistake, or even it just failed. Nothing is 100%. Yeah. So if it failed, right? It is close to 100%, but it's yeah, very close, but not 100%. But there are re there are documented failures, absolutely, there are documented failures, right? So the risk to the community then is that if you keep you don't know your HIV positive because you have no symptoms and you didn't test and then every time you have a sexual encounter, you're taking your 211. So you keep exposing the virus that you've caught unbeknownst to you, you've caught several months before to this drug.

SPEAKER_01 1:17:29

Yeah.

SPEAKER_05 1:17:29

You're gonna hone out a a virus that's resistant to that drug. So even other people if you're all of your sexual even if they're on prep.

SPEAKER_03 1:17:38

Because they're taking the same drug, so they're resistant to that drug. Yeah.

SPEAKER_05 1:17:42

Right. Oh my god, I didn't know that. That was an argument in that was the pushback that we got when we were talking about bring rolling out prep. We got lots and lots of pushback saying this is going to be loads of resistance and this is not gonna work. And in this sort of why are you supporting this behavior type of thing? Right. Yeah, yeah, yeah. But it's never put your willy back in your pants. It's never materialized. It is never materialized, but but it is it is it's important to be cognizant of that. And one of the reasons it's never materialized is how effective the drug is, but also how compliant our caseload are.

SPEAKER_03 1:18:14

Yeah, yeah, absolutely. It's just something I think it's just something to consider, like the importance of testing, right? So it's it's highly, highly effective. Yeah, yeah, doesn't preclude the reason to get regular testing. Yeah, so it's not just I now take this, I never need to go anywhere. I never need to go anywhere. Yeah, because it's a bit like antimicrobial resistance, like if we don't take it as prescribed, things can go wrong. So it's not meant to scare anyone, you know, truthfully, like, you know, oh my god, I'm gonna have this resistant strain of HIV and I'm gonna infect everyone. That's not what we're trying to sort of elicit, but what we're trying to say is that just because you're on this drug doesn't preclude you from getting regular testing, it's for your safety and for the safety of the community, essentially.

SPEAKER_01 1:18:55

Yeah, no, that's important. I think it's important to know. That's kind of what we're we're trying to get at. It's like when people put on steroid gloves and they think they can touch everything. It's like you can't, you know.

SPEAKER_03 1:19:04

You just can't. True? Yeah, true, it's actually true. Like like nothing. I think the thing is like, you know, this whole reason we're doing this podcast is just to just kind of just uh dismantle the fear a little bit, I suppose, and just acknowledge that nothing is ever 100% in medicine in life in general, and we have lots of things in place to keep us safe. It just involves just you know, trusting a health professional that we're not doing this to sort of be punitive or annoying. We're just trying to keep you safe, is all we're trying to do.

SPEAKER_01 1:19:34

And sometimes a little bit of fear is good. Just a little bit.

SPEAKER_03 1:19:40

It's like when Fergus walks into the office and says, hi, Beryl. Okay, Fergus. Okay, go, go, go. Okay, okay. I think that's all we want to talk about. Prep. I feel like I've for some reason it's happened. I think it's gorgeous. Gorgeous. Yep, yep.

SPEAKER_01 1:19:53

That's perfect.

SPEAKER_03 1:20:03

Um, so tell us a little bit about Doxy Pep.

SPEAKER_05 1:20:11

Okay, so Doxy is Doxycycline, which is an antibiotic. Right? So tetracycline is the fancy name, right? It's one that lots of people will be familiar with. Fancy, like your hat. Oh my.

SPEAKER_00 1:20:21

I couldn't wear my hat.

SPEAKER_01 1:20:22

We could put it over the headphones.

SPEAKER_00 1:20:24

We could have. We should have. We're in our second bottle, I'm so sorry.

SPEAKER_02 1:20:29

Yeah, take it, take it, look at him, look at him. Oh my god, Mr. Jasmine.

SPEAKER_03 1:20:34

Mr.

SPEAKER_02 1:20:34

Jasmine.

SPEAKER_01 1:20:35

Stunning.

SPEAKER_03 1:20:36

Did I tell you, just as a side note before we talk about Doxie Cap, we have our staff party this Saturday. I have mine this Friday. And I said to Fergus, Ferguson, that he can only come if he wears a tutu.

SPEAKER_01 1:20:48

I've got heaps.

SPEAKER_03 1:20:49

Great. I actually ordered one.

SPEAKER_05 1:20:51

Is this a Santa Kini work?

SPEAKER_01 1:20:52

Yep. Even better. Oh my god.

SPEAKER_00 1:20:55

Where is your where is it?

SPEAKER_03 1:20:56

Is it Flight Club? In Frio? No. Is that this Saturday? You're just doing that to piss me off, aren't you? At least you paid me, so that's fine. Okay, continue. Doxypex. Sorry, sorry, sorry.

SPEAKER_05 1:21:14

So doxycycline is an antibiotic. It's the one that a lot of people would be familiar with that you take for acne, for instance. Malaria prophylaxis. Malaria prophylaxis if they're going on a trip and their doctor doesn't like them and PEP stands for post-exposure prophylaxis. So what we've been talking about before is HIV prep pre-exposure prophylaxis. This is afterwards. And this covers you for the previous three days, 72 hours, and it gives you protection against some of the STIs, not against HIV. So particularly against syphilis, and give us the staff chlamydia. So it gives us 80% protection against syphilis, 70% protection against chlamydia, about 45% protection against Australian strains of gonorrhea because of antibiotic resistance, which in Dublin, as we say, is better than a schlep in the eye with some shit in the end of a stick.

SPEAKER_02 1:22:04

Sorry. Sorry. Okay, sorry. Okay, sorry.

SPEAKER_03 1:22:09

Say it again. Sending it, sending it, sending it, sending it, setting it, sending it, saying it, saying it, say it again. Say it again.

SPEAKER_05 1:22:14

Say what?

SPEAKER_03 1:22:14

Say that again.

SPEAKER_05 1:22:15

It's better than a slap in the eye with some shit in the end of a stick.

SPEAKER_03 1:22:23

So can't wait for that ground.

SPEAKER_05 1:22:25

So good. So so so yeah, so you take two doxycycline, ideally within 24 hours, but a little bit like the emergency contraceptive pill. You've got to think of exactly like that. Exactly like that, right? Right, yeah, right. So it's better that bridging the gender gap. It's better than it's better the sooner you take it.

SPEAKER_03 1:22:42

Yeah.

SPEAKER_05 1:22:42

But you can take it up to 72 hours, right? You don't have to take it after each event, it will cover you for the previous 72 hours. So if you've gone to Pride and you've hooked up on Friday night, Saturday night, and Sunday night, at Sunday night after your last partner takes two tablets, protects you for Friday, Saturday, Sunday. It's your birthday, you've been partying three nights in a row, you take two tablets. Or, you know, like I've got uh patients who, for instance, might go on a gay cruise, for instance, every two days they take two tablets. Yeah. Right? So for high risk. Every two days or every three days? Sorry, every three days. Yeah, that's right. Sorry, sorry.

SPEAKER_03 1:23:13

Every three days, yeah, yeah, yeah. Every three days they take two. Did I know something more than you just then?

SPEAKER_01 1:23:18

Potentially. Who knows? Two tablets every three days? Correct. Seven two hours.

SPEAKER_05 1:23:25

Yeah, yeah, yeah. And so it gives you that degree of protection. Now, obviously, there's negatives, right? So the overuse of antibiotics, we all know that we want to try and avoid antibiotic resistance.

SPEAKER_03 1:23:34

We love doxycycline too. I love doxycycline. It's such a good antibiotic.

SPEAKER_05 1:23:38

It is, right?

SPEAKER_03 1:23:38

So I was such a nerd. No, no, no, I'm with you. I'm with you.

SPEAKER_05 1:23:42

Why is it good? Why is it good?

SPEAKER_03 1:23:43

Well we just use it for so many different things and it hasn't developed resistance yet, right? So, like acne, chest infection, sinus infections, malaria prophylaxis, chlamydia. Like it's uh and also syphilis, right? Like it has been used and it hasn't developed resistance. So we love it. We love gonorrhea. It's highly effective. Yeah, for that point.

SPEAKER_05 1:24:02

And wh why don't you use it for gonorrhea?

SPEAKER_03 1:24:05

Because of resistance.

SPEAKER_05 1:24:06

So it does develop resistance, then we need to be cognizant of that. So it does. It does. No, but you're right, it's got a high level of resistance. Yeah, yeah. But if you think about it, you're you guys are probably a little bit young for this, but the old man and the other.

SPEAKER_03 1:24:19

It is hard when you're 105 years old.

SPEAKER_05 1:24:20

So what in in the past, what did we use for chlamydia? Azithromycin. Yeah. Why don't we anymore? Resistance. And yeah, why do we have resistance to azithromycin? There's lots of answers to that. Why are you mad at him?

SPEAKER_03 1:24:32

This isn't even a true and false. And you're like answering all the questions like, yeah, okay, no worries.

SPEAKER_05 1:24:36

So why why why I mean there's different there's different there's there's ris res reasons, that antibiotic has reasons why it's developed resistance, right? And it was originally one of the if you there's not a lot of new antibiotics come out in the market because the drug companies won't fund and put lots of research into it, right? Uh and so that that's one of the more newer ones, even though it's actually quite old now, but it can't and it came out with all of this you know uh pomp and ceremony, but it actually quite quickly developed resistance.

SPEAKER_01 1:25:01

Yeah.

SPEAKER_05 1:25:02

But one of the reasons why it developed resistance is because in sexual health, our antibiotic husbandry has been shit for a long, long time, right? Sorry, because antibiotic antibiotic husbandry. So how we look at antibiotics.

SPEAKER_00 1:25:15

Okay, you are wrong.

SPEAKER_01 1:25:17

Because I speak never because I speak English. I've never heard of antibiotic antibush, please discover it.

SPEAKER_05 1:25:26

So so our vigilance, how we look after antibiotics and protect antibiotics. Well, it's because husbands are like the ones. Yeah, maybe it's well it's from the language from the uh the meaning of the word, but yeah, maybe, maybe it's not.

SPEAKER_04 1:25:37

Yeah, yeah, yeah.

SPEAKER_05 1:25:38

So so in the past, all of the sexual health uh guidelines were designed to treat the person with a with a potential STI or a potential exposure to an STI as a public health hazard. For their MSM population, they were a dick without a brain. They were gonna walk out the door with their potential chlamydia gonorrhea or syphilis and fuck everybody that they walked past. Right? It was completely untrue, right? So what they came in with saying that they were a contact or they had minor symptoms, and our guideline was treat them with everything. Yeah, give them everything. Yeah. Because you'll hit one of them, right? Yeah, yeah. And so we just blasted them with antibiotics and created resistance. I mean, like the mycoplasmagenital story. Oh, don't listen.

SPEAKER_02 1:26:20

Don't even get me started. Yeah, yeah, yeah.

SPEAKER_05 1:26:22

So now those guidelines are much more enlightened. Now you have a conversation with a sentient, responsible person at the other side of the table, and you say, Do you know, do you are you happy to wait and we'll target with what you've got. If you're really uncomfortable symptoms, we'll we'll target the symptoms with the best we can, right? And we'll g we'll give you these treatments. Now, the doxypep story flips that on its head a little bit, right? Because we're now saying, okay, we're now going to swamp the market with an antibiotic and get people to use the antibiotic, either may perhaps maybe following the it's not a guideline, it's a it's a consensus statement, really, from actually my professional body, right? And even the politics of that, where that's come from, is interesting, right? It wasn't driven by doctors and by medicine, it was driven, and and I'm not saying that this is wrong, but it was driven by the by the the customer base, the the men who have sex with men who wanted protection, which is fair enough. Yeah, and they were aware when they asked of the potential risk of resistance, they weren't ignorant from that to that, right? So so if we were to use Doxy Pep in a way that we say everyone can just get doxypep and take two tablets, then you're gonna have a lot of people taking it who probably don't need it, a lot of people taking it who might be just treating the anxiety a little bit like we said HIV anxiety can be treated illegitimately with PrEP. Whereas here we might develop resistance. And you're a beautiful antibiotic, that you're absolutely right. I love it. If you do ID training, they love ID ID doctors love doxy, right? For that reason, right? It's a really useful antibiotic, yeah, yeah, yeah. Right? So, and in the studies, the doxy prep studies, there was some signal of resistance, but not statistically significant. My interpretation of that is the Studies weren't big enough. Yeah. And then and also they were, you know, you're looking at statistically significant or you're looking at resistance to the tetracyclintodoxy in in the STIs. But what about your gut flora or your skin flora? Absolutely. So it's a so it's a it's a complex story. Yeah, it is. It is. It always is. Yeah. So originally, if you look at the trials, there's a really nice little number needed to treat uh uh table, right? And a number needed to treat is a is a is a way of trying to turn statistics into a very understandable form, right? So if you give everybody that's sexually active or every PrEP patient doxy, right, you're gonna have to treat 24 of them to avoid one case of syphilis, right? Or one STI, right? If you give somebody who's had syphilis in the last 12 months, has had two or more STIs in the last 12 months, goes to a sex on premises site, or is going on a traveling overseas and going to be sexually active, you've got to give five people. So that's much more targeted. Yeah, I see, I see, I see. So the original guidelines were give it to patients that are higher risk. Yeah. Have had multiple STIs, have had syphilis recently, are going on a sex holiday, or are going to sex on premises sites or uh sex parties. And that's what so for instance, that's that that was our guideline in the M clinic, right? Now there's an argument driven which is a very legitimate argument, and it's definitely won me over, that's the rates of syphilis are so high in WA and that it's crossed over now into the heterosexual population. We unbelievable syphilis episode unbelievably have congenital syphilis now, right? That there's an argument now that we have a public health response and that you can say doxypep could actually be a very potentially a very effective way of driving the level of syphilis down in our population. Yes, because that's where we are.

SPEAKER_01 1:29:49

So I see what you're saying when it was doxype was 80% effective at um decreasing your risk of getting syphilis. And again, we're talking about the risk-benefit scenario. Yeah, absolutely. That it's also the greater good that kind of vibe. Yeah.

SPEAKER_05 1:30:05

So what I say to my patients, or what we say to our patients at the moment, is yes, we we whereas before I was assessing risk and saying, well, no, you don't meet the risk, and this is I wouldn't say no, you can't have it. It would be I talk to them about the antibiotic resistance risk, right? And weigh it up. But and and we were quite discerning, right? Now we are offering it to people on in this attempt, and we say, I don't know for how long, maybe six to twelve months. And then I'm saying that in six to twelve months, we're gonna look at the numbers, and if this isn't working, we're gonna be pulling this back. I see because we're gonna regret this otherwise.

SPEAKER_01 1:30:35

Kind of sort of a yeah, kind of kind of yeah, yeah, yeah. Yeah, interesting. No, it's so interesting. Yeah, yeah.

SPEAKER_03 1:30:42

Okay, so um so Oh, and you know the other thing that's really important here.

SPEAKER_05 1:30:47

Yeah, please we're talking about men who have sex with men or bisexual men or trans women. Yeah. Doxype is not effective or not proven effective for women.

SPEAKER_03 1:30:56

Correct. Right? Wait, what? Right cis women.

SPEAKER_05 1:30:59

Cis women. It's not it's not proven that it's not effective, it's just not proven that it's effective. And there was a very large Kenyan study that more or less suggested it wasn't effective. Yeah. But that's a study that needs to be done. So it's not something that was is necessarily something that we should be rolling out to women because of that.

SPEAKER_01 1:31:17

Yeah. No, that's fine. Not that I'm taking docs prep, but there was one moment where I had sex with a guy who was like, oh, by the way, I'm recently exploring my sexuality. And I was like, oh true, didn't know that next day that popped a couple of docs in. I was like, but true, good to know. Oh, we have to start wearing condoms please. I'm so mad. We have to start wearing condoms please. Condomics. Continue, continue.

SPEAKER_03 1:31:37

No, no, no, it's fine, it's fine, it's fine. Um, so I feel like you've you've covered quite a bit. Is there anything else you want to add about Doxy Pep before I do my summary?

SPEAKER_05 1:31:46

Uh no, other than to say, you know, again, uh, you know, I think I think, and this might be a useful sort of theme anyway, that's very often patients are, you know, particularly particularly the MSM population or the BMSM population, if they rock up to their standard GP, they may not necessarily get a very uh receptive welcome because of awkwardness in taking a history, awkwardness in asking the right questions, not knowing or feeling comfortable to ask their sexual practices, so not knowing what sites to test and things like that, or not knowing about Doxy Pep. I think it's perfectly reasonable that a GP doesn't know about Doxie Pep. I think what what's is also perfectly reasonable though, if you as an informed person go in there with that information and hand them that information, and you can get that on our website or Ash the Ashams website and just go, these are my risks, this is my practice. It's okay for you to have this conversation with me. I'm more than happy to have this conversation with me. You don't need to feel awkward, and this is what I would like. 100%. You know, like I've in in my clinic in the in the steamworks, we do it on a Thursday night. I got a young Irish guy come to me and say, What is it with this? Because he picks my accent at the time. He said, What is it with this country? You can't get prep anywhere. I've gone to six GPs and asked for PrEP. I'm a highly sexual active gay man, I'm high risk, and they've all told me no, what I get it in a second in Ireland.

SPEAKER_06 1:33:05

Yeah, right?

SPEAKER_05 1:33:06

And so that's right, so that we need to counter that. And I think the we we as a profession, we've got a role in education and countering. We do, we do, absolutely. But actually, the most powerful agents are the are the clients.

SPEAKER_03 1:33:18

100%, right? Like the whole purpose of this is to give you autonomy and empower you to be able to come to your practitioner and say, hey, this this is what I want, these are my risks. And I think that's really important because you know, as a GP, we don't we don't know everything, you know, guys. We've we've got to do a lot of things, and there are some of us that you know we'll will know more than others. And we've said this before in previous episodes is that if you help you, yeah, if you help us to help you, but if you feel dismissed by a GP, find another one, right? Like don't don't feel like we we've said this before, right? The therapeutic relationship is really, really important. Yes, and particularly with your GP. And if you feel like you're being dismissed, there is going to be someone out there that is a good fit for you. Keep trying. Keep trying, definitely.

SPEAKER_01 1:34:00

And yeah, I just wanted to mention, because I forgot, um, a friend of mine spoke about um like new clinics that have been opened up at um South Terrace and Fremantle. I'm sorry, at South Terrace and Royal Perth, which was specifically for prep for people without Medicare. Correct, yeah, that's a really good point. That's a really good point. So apparently these are these are clinics that have been opened up that actually aren't that busy, which is free prep for people without Medicare. So I get a lot of phone calls on the helpline for people without Medicare wanting prep. And um yeah, so this is this is now opened up. Yeah, yeah. So Royal Perth and and and South Terrace.

SPEAKER_05 1:34:32

Yeah, which is which is great, and that funding was put up. It's it is unfortunate that it's in a setting that's only open on during work hours.

SPEAKER_03 1:34:39

Yeah, yeah. Yeah. Look, yeah, I think it's it's tricky. I mean, I mean, access is we've just established that sometimes perhaps you go to a GP and they don't know that's a barrier to access. Public hospitals who offer uh subsidized or free medication if you don't have Medicare, the business hours, there's lots of barriers, I suppose. And we acknowledge that and we are working as best as we can with the system, but we do want to reassure you that it is available. All this stuff is available, you might just have to do a little bit more digging yourself. Um and I do think in terms of in terms of access, I probably do just want to touch a little bit on. I'm so sorry. You someone literally fed back, was like, you need to stop talking about touching. Okay, we're gonna stop. Yeah, we're gonna stop talking about that.

SPEAKER_01 1:35:22

No, no, I didn't stop talking about you can say touching it. But not make a joke. Yeah, I made a joke about it though. No, it's not. You're perfect.

SPEAKER_03 1:35:28

You're literally the perfect person. No, you're perfect. You've never done a wrong thing in your life, go. No, you're perfect. No, you're perfect. Um so in terms of accessing PrEP and DoxyP, um, and the MPOX vaccine, actually, is it can be done through your primary care physician and GP Clinic. Um in terms of out-of-pocket costs, it might be the the cost of the the consult as per the practice that you go, but the vaccine itself is free and the medications will the the doxycycline is not on the PBS for this this indication, so you'll have to pay privately for that script, but it's not it's generic and it's incredibly cheap.

SPEAKER_05 1:36:00

Yeah, it's so cheap. Actually, if it was on the PBS, it wouldn't make any difference.

SPEAKER_03 1:36:03

Wouldn't make any difference. So don't worry about the cost of that. And similarly, it's on the PBS, so that's not a problem. If you find that your GP is not comfortable or you feel like you're not being heard, then there's obviously clinics that you can access like uh um and you know, we've we have talked a lot about WA and Perth in this episode because we're all from here, obviously. Uh, but you know, each state and territory will have their own community sexual health clinics that will have access to these services. So do your research. Yeah, each state and territory will have one. You can certainly access these services there. There may be a fee as well. Um, and then the public hospital systems are certainly more equipped for people without Medicare. We certainly, you know, uh in in Perth we sort of see everyone, but I know that um, for example, New South Wales will only certain uh prioritize certain populations for their public health um services like homelessness and um no Medicare and things like that. So I know it feels like sometimes there's a there's a big barrier to accessing these services because you know we've we briefly touched on the the the stigma that um MSM face as well. But you know, we have highlighted this there's actually quite a bit out there. You just have to access it. Yes and once you're in the system. And once you're in the system, you're in. Um but you know, if you have a good practitioner and a good service, we will take all of that into consideration. Okay, you know, find somebody that you trust. You should also look at finding a practitioner that's not just gonna do your prep or doxypep or epox, you know, having a long-term therapeutic relationship with a GP. It's not just about the fact that you're a man who have who has sex with men. There's lots of other things that might happen in your life, so that's really, really important as well.

SPEAKER_01 1:37:33

Yeah. No, just give me a few.

SPEAKER_03 1:37:39

You'll find him, find him at SteamWorks. This has been so much. I do just want to summarize summarise Doxy Pep just very, very quickly. So DoxyP is the use of doxycycline antibiotic, um, which we love because it hasn't really developed a lot of resistance potential, but there is there's a possibility of that. You take two tablets within 72 hours of an unprotected encounter, no more than two tablets every 72 hours. Um we do have a general fear about antimicrobial resistance, but in the context of a syphilis epidemic, we're just gonna be a bit more generous with it, essentially.

SPEAKER_05 1:38:19

The benefit might weigh outweigh the harm.

SPEAKER_03 1:38:20

The benefit outweighs the risk or the harm. We didn't talk about the side side effects of doxycycline, but just briefly. Um it can give you a bit of reflux, increase your sensitivity to the sun. Um its absorption is affected by some other things that you might take zinc, calcium, iron, um, antacid tablets. So just make sure you tell your healthcare um professional that you're taking it. Um it's not a private script, but it's dirt cheap, essentially. Um, and you take it, yeah, as I said, two times.

SPEAKER_05 1:38:46

Can I intervene?

SPEAKER_03 1:38:48

Okay, Ferguson. Run, run, everyone, run for cover. He doesn't like my summaries anymore.

SPEAKER_05 1:38:52

No, no, I do. I love your summaries. I just I just realized we forgot something.

SPEAKER_03 1:38:55

Did I hear that Fergus loves me? Is that what you heard? Yeah, you're you're fabulous. I didn't give you any rhine because I know you're done. Fergus loves me. Can't wait to tell Belgium.

SPEAKER_05 1:39:04

Sure, sure. So just to I mean, uh uh it's important too that because of this sort of case that we we we deal with obviously people will ch will chop and change and and provide medication to their friends and say, Oh, I've got some, here's some. And there are some medications that interact with doxy potentially dangerously. Yes. So you just have to just get it from your health professional, right? Like, we're not nodding.

SPEAKER_03 1:39:28

Yeah, we've obviously identified that some GPs will be a barrier, but not all of us will be. Okay. So if you don't see focus at that.

SPEAKER_01 1:39:34

Really important, like when we talk about resistance as well, because often we find that happens whether or like you'll divide your meds up between you and your partner, not you know, you do need to finish the whole course, like when it is treatment for climate and things like that, in order to reduce resistance. So, yeah, don't just share your meds with your partner, get them to come in. And we'll just give them their own meds.

SPEAKER_03 1:39:57

Right. Um, I think my summary's done though. Oh, are you sure? Yeah, I think so.

SPEAKER_05 1:40:02

I was so looking forward to that.

SPEAKER_03 1:40:06

Oh my god. Uh but basically you can access it from uh from any five, like I've lost my train of.

SPEAKER_01 1:40:13

No, come on.

SPEAKER_03 1:40:14

No, like uh I mean I guess this whole episode is about MSM, but we acknowledge that men who have sex with men also have sex with men. There's lots of different sexual practices that are happening. PrEP, Doxy Pep, and the MPOX um virus and vaccine have been relevant to that population, but this is probably changing as time goes on. We certainly haven't spoken about PrEP in um AFABS as well, which is is is something that could potentially could be indicated, but we probably won't go into that. I think that could be another episode. But basically, if you are a man who has sex with men in general, um maybe look at these things as a as a something that can basically protect you, keep you safe, but give you bodily autonomy um without judgment or fear.

SPEAKER_05 1:41:00

Do you know what we've forgotten? Fuck A and Hip B.

SPEAKER_03 1:41:04

Yeah, I know, but I like I didn't really talk about that. I'm not to uh That's okay. We've covered We've literally been talking about two hours. It's a it's quarter past nine.

SPEAKER_05 1:41:12

We've booked just get hepe vaccines.

SPEAKER_03 1:41:15

Just get your vaccinations, just go to your GP and do what you're told. It's chill.

SPEAKER_01 1:41:21

There's uh you know, I mean I promise, yeah, it's it's chill.

SPEAKER_03 1:41:25

It's chill, it's actually chill. We've been talking for two hours about this. But like, it's all about safety, right?

SPEAKER_01 1:41:30

That's what we're trying to do, is just keep you safe. See focusing said. No, he's not taking new patients.

SPEAKER_03 1:41:36

And we see more.

SPEAKER_01 1:41:37

He's not taking new patients. Yeah, so your local sexual health profession. But this has been I mean, I've learnt so much. Thank you so much. Especially, yeah, I guess someone who works really closely with all of this, but yeah, as I said, doesn't I don't do my own consult, so like oh I I feel like it's all kind of clicked into place today for me.

SPEAKER_03 1:41:56

Anyway, so thank you. Yeah, it's been I learned nothing new because I'm really smart. Oh my goodness. No, just kidding. I learned a lot. I learned a lot. I'm just kidding.

SPEAKER_05 1:42:04

I learned that you can actually sit without that ridiculous barrel jacket on.

SPEAKER_03 1:42:07

Oh fuck you. Listen, listen. I rock up to work in my scrubs, but sometimes I'm a little bit cold, so I wear an oversized I wear an oversized puffer jacket.

SPEAKER_01 1:42:19

She wears an old lady's Okay, I am so glad that I did not wear my jacket in tonight. She's only sure to have her curlers on when she comes out of the drinking.

SPEAKER_03 1:42:28

One day I'm gonna come to work in my curlers just to piss him.

SPEAKER_01 1:42:31

Mine is like a zipped up sleeping bag that I walk in. I walk in.

SPEAKER_03 1:42:35

It's cold sometimes. It's my anxiety jacket, okay? Yeah, yeah. I get nervous when I face you, Fergus, to be honest. Just kidding, just kidding. So grateful that you've come on today.

SPEAKER_00 1:42:44

It's really fun.

SPEAKER_03 1:42:45

Did you have a good time? Fun, really fun. Great. Okay, stunning. Okay, we just we hope so.

SPEAKER_01 1:42:51

We hope so. And we love it. We'll have you back on. We'll keep going. Yeah. As we've learned, there is so much to discuss. So much to discuss. Every time we talk about something, another topic unfolds. I know. Um, but we'll keep getting new guests in and we'll keep unfolding with you, and we hope that you unfold with us. We love it.

SPEAKER_03 1:43:08

We love, we love unfolding. We love. Okay, don't forget to like and subscribe. Like and subscribe. Um, follow us on Instagram. We're on Apple and Spotify, wherever you get your podcasts, send us some fan mail. Send us an anonymous message. We love voice notes. Yes. Sing us a song as well. We enjoy that too. And if you want to hear about anything in particular, we're open to feedback. Um if you want me to talk less. No, that's never. No, that's crazy. If you want me to summarize less, no, that's even more. That's crazy. If you want less stuff, no, that's we love this. You're perfect. You're perfect. We didn't sing in this episode. Next time. So sorry. Next time. Next time. Okay, bye!

SPEAKER_01 1:43:47

I love you bye.

SPEAKER_03 1:43:50

For Goodness' Sex is produced and edited by me, Dr. Shamani, social media and visuals by Nurse Ellie, with audio assistance by Avesta Zanel. We couldn't do it without our management team, Louisa and Sarah, the Hen House Recording Studio for hosting our recording sessions, and Tapari Sound Safari for our music. Don't forget to check out our show notes for all our recommendations and to send us a text with your questions, queries, stories, or feedback. We love hearing from you. Thanks for listening.