#41 PrEP For HIV Prevention- Help From The Curbsiders

In addition to this post please see these others posts about the screening and treatment of sexually transmitted diseases (STDs):

Knowing how and when to take a sexual history is a critical skill in the diagnosis of STDs.

Today I’ve embedded the podcast of the CurbsidersEpisode #41 below [for my convenience]

And here is a link to the outstanding show notes [I’ve placed the show notes in this post]. And see Additional Resources below for help from the CDC on PrEP.

Case: 25 yo M who wants to start a family with his wife who has HIV and is on HAART with undetectable levels.

Clinical Pearls:

  1. Tenofovir and Emtricitabine (fixed dose combination) taken once daily. Side effects nausea, flatulence, and headache are most common. Usually subside in 1 week to 1 month. Long term risk = renal toxicity, and loss of bone density. Continue medication unless Creatinine Clearance (CrCl) drops below 60 ml/min.
  2. Three groups who may benefit from PrEP: Men who have sex with men (MSM) who are at high risk; Heterosexual men and women who are at high risk, especially if HIV discordant couple; IV drug users (IDU). High risk = inconsistent condom use, multiple sexual partners, reside in location with high prevalence HIV and STIs, partner is HIV positive, sex workers, and injection drug users.
  3. PrEP baseline testing: HIV within 1 week of initiating PrEP, Hepatitis B serologies, Calculate CrCl, sexually transmitted infection (STI) screening
  4. STI screening: HIV, oral and rectal swabs for gonorrhea (GC)/chlamydia, and urine probe or urethral swab for GC/chlamydia. Check RPR for syphilis. Check Hepatitis C antibodies if MSM.
  5. PrEP provides 90% reduction in HIV transmission if perfect adherence. Real word likely 40-50% reduction.
  6. PrEP adherence: Counsel on daily use and prepare/coach them through side effects.
  7. Monitoring on PrEP: Follow up in 1 month to assess high risk behaviors, side effects, medication adherence. CDC guidelines recommend checking HIV status at least every 3 months, and CrCl at least every 6 months. Check CrCl more frequently if comorbid conditions e.g. HTN, DM2. Screen for STIs every 6 months, but consider checking every 3 months if high risk population.
  8. PrEP coding: Use ICD 10 code: Z20.6 Contact with and (suspected) exposure to human immunodeficiency virus [HIV]
  9. Development of HIV viral resistance to PrEP is very rare. Less than 5 cases reported.

Additional Resources [All of these excellent resources are from Episode #41 above]:

(1) Pre-Exposure Prophylaxis (PrEP) [For The Prevention Of HIV Infection] From the Centers for Disease Control and Prevention (CDC).

Pre-exposure prophylaxis, or PrEP, is a way for people who do not have HIV but who are at substantial risk of getting it to prevent HIV infection by taking a pill every day. The pill (brand name Truvada) contains two medicines (tenofovir and emtricitabine) that are used in combination with other medicines to treat HIV. When someone is exposed to HIV through sex or injection drug use, these medicines can work to keep the virus from establishing a permanent infection.

When taken consistently, PrEP has been shown to reduce the risk of HIV infection in people who are at high risk by up to 92%. PrEP is much less effective if it is not taken consistently.

PrEP is a powerful HIV prevention tool and can be combined with condoms and other prevention methods to provide even greater protection than when used alone. But people who use PrEP must commit to taking the drug every day and seeing their health care provider for follow-up every 3 months.

(2) Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men [PubMed Abstract] [Full Text HTML] [Full Text PDF].
N Engl J Med. 2010 Dec 30;363(27):2587-99. doi: 10.1056/NEJMoa1011205. Epub 2010 Nov 23.

(3) On-Demand Preexposure Prophylaxis in Men at High Risk for HIV-1 Infection [PubMed Abstract] [Full Text HTML] [Full Text PDF]. N Engl J Med. 2015 Dec 3;373(23):2237-46. doi: 10.1056/NEJMoa1506273. Epub 2015 Dec 1




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