1. Alyson Decker, NP, MPH Clinical Prevention Consultant
San Francisco Department of Public Health
As part of the city’s Getting to Zero campaign and the national response to eliminating HIV, the SFDPH is trying to increase HIV pre-exposure prophylaxis, or PrEP, prescribing in the city to individuals at risk for HIV infection.
Have you heard of PrEP? ………

2. What is PrEP?
PrEP is a once-daily pill for HIV negative individuals that can help prevent HIV infection.
PrEP is FDA approved as a combination, fixed-dose antiretroviral medication called Truvada®.

3. PrEP can “do more” than prevent HIV
Empower receptive partners to take control of prevention
Reduce the burden of HIV anxiety
Reboot conversations about HIV prevention
Connect patients to primary care and insurance
Improve our approach to sexual health
Empower:
PrEP can empower receptive partners to take control of prevention. PrEP is the first HIV prevention strategy that is truly in the receptive partner’s control without negotiation or discussion with the insertive partner (as was the case for the female condom). This is a truly powerful innovation, that has the potential to have a positive and empowering psychological impact.
Anxiety:
A lot of people have been talking about this anecdotally – PrEP as an anti anxiety medication.
Reboot:
PrEP can be used to move outside the “scripts” of “You use condoms every time you have sex, right?” to actually talking to clients about what they are doing and what they want and need to do to protect their sexual health.
PrEP can allow us to move beyond the “see not evil” represented in the monkey picture to ask about clients’ ideal sex lives and/or definition of sexual health.
Giving clients permission to tell us that they don’t always use condoms can open up real and better conversations about HIV prevention strategies
4. Connect:
PrEP also has the potential to bring clients “in” to medical care who might not ever see a reason to go to the doctor. PrEP a “gateway drug” to medical care
Coming regularly for HIV and STI testing allows increased access to other types of care that patients might need
Needing to pay for PrEP might help engage someone in health insurance (e.g., Medicaid), when they never had a reason to apply before
5. Improve:
And last but not least, PrEP can help improve our approach to sexual health. Going beyond even the 1:1 conversations with clients, PrEP has the potential to help us as providers think about the sexual health of our clients more broadly and holistically. PrEP requires us to TALK to patients about their sex lives, and to manage their care as part of their overall health. What could be better than that? Could PrEP have a domino effect that could improve sexual health care more broadly?
Golub SA, NYC DOHMH, 2016

4. Who may benefit from PrEP?
Men who have sex with men (MSM)
Trans women
People who inject drugs
Heterosexual men and women
Risk
Recent history of syphilis or rectal STD (high priority)
Anal sex without condoms
Multiple sexual partners
HIV+ sex partner
HIV+ injection partner
Shares needles or equipment
Transactional relationships
“High priority populations for HIV preventative care.”
*** “Anyone who wants to take control of his/her sexual health regardless of partners or circumstances of having sex.”
“In modeling, the number needed to treat was lowest among those who have condomless receptive anal intercourse.”
“For females, their risk is often an extension of their partner’s risk (bisexual male partners, IDU)
Anyone who asks for PrEP

5. Case
Marcus is a 27 year-old male who has never been seen by a primary care provider and presents to initiate care with you.
How do you ask him about his sexual health?
Let’s review a case so I can understand more about PrEP and how you discuss it with patients in your practice.

6. How do you take a quick sexual history? Ask about “PrEP”

7. Case Marcus, can you tell me more about your sex life?
We made up a pneumonic that I find helpful for remembering what to elicit during a sexual history.
Studies have shown that patients are not great at estimating their own HIV risk.
“Can I tell you more why people similar to you choose to use PrEP?”; Would you like to hear more about PrEP?
“Why are you not on PrEP?”
“Is it possible that PrEP could move you closer to your ideal sex life?”
Some patient quotes: “more health conscious in general”, “extra layer of protection”, “more comfortable and free”
What are your thoughts on Marcus’ risk for HIV?

8. Focusing on reported benefits of PrEP…
“Here are some things people say about taking PrEP”
“I feel good. It's like an extra layer of protection.”
“Feeling more comfortable and free during sex and in life.”
“Less shame about my sexual habits."
Another strategy for presenting information about PrEP is talking about the reported benefits. Not only focusing or risk reduction – “you should take PrEP because your risk assessment tells me you are at high risk of HIV infection” – but focusing on [CLICK] Let me tell you about why people like you choose to engage in HIV prevention…
Here are a couple of quotations from people in the NYC PrEP demonstration project about why they chose to stay on PrEP.
“It’s made me more health conscious in general.”
“Opens up doors to date HIV+ w/out same kind of worry ”
Source: SPARK PrEP Demonstration Project; R01AA (Golub, PI)

9. We are providing a patient educational tool to help patients remember some of the important points while taking PrEP.
Truvada is safer than aspirin.
“Messaging has not been clear so we are just telling patients that PrEP is >90% effective, not 100%”. “consistent with messaging”

10. The 3 Keys to Starting and Tracking Patients
PrEP Prescription
Clinical Evaluation $
Labs
Financing
PrEP Prescription
Starting with first visit, and every 3 months after

11. Baseline testing Screen for symptoms of acute HIV infection
HIV test within 7 days (4th Generation Ag/Ab test preferred)
STD testing (GC/CT urine, pharyngeal, rectal; serum RPR/VDRL)
Creatinine (contraindicated if CrCl <60 ml/min)
HBV surface antigen
HCV antibody
Pregnancy test
Pocket Card
“Do you screen patients who have receptive anal intercourse with rectal GC/CT swabs?”
Risk of HIV resistance if patient HIV infected when beginning PrEP
Renal elimination of Truvada thus risk if underlying renal impairment/dysfunction
STI: GC/CT (site specific testing if available) and RPR/VDRL
Opportunity to screen patient for hepatitis and immunize if non-immune; Also risk for HBV flare when Truvada discontinued if patient has chronic HBV infection

12. PrEP Pocket Card

13. Assess risk for acute infection at PrEP initiation

14. * TAF/FTC (Descovy) is NOT approved for PrEP
ICD-10: Z Contact with and (suspected) exposure to human immunodeficiency virus [HIV]

15. Follow-up every 3 months…
Screen for symptoms of acute HIV infection
HIV test
3-site STD testing
Creatinine (q 6 months)
HCV Ab (q 12 months)
Pregnancy test
Consider standing orders, order templates/order sets for f/u visits.
* Patients should report to clinic immediately if they develop symptoms compatible with acute HIV infection (fever with sore throat, rash or headache).

16. The majority of CT/GC infections will be missed if only urine is screened
Kent et al., Clin Inf Dis 2005

17. Make labs easy Standing orders Self collection of STD swabs
Posters for your bathrooms
SHOW IMAGES OF SELF-SWABBING
University of Washington STD Prevention Training Center

18. Case
Marcus returns to clinic 4 months later. He was taking PrEP daily but his prescription ran out last month. He would like to continue PrEP and requests a new prescription. Marcus reports having condomless anal sex 2 nights ago.
Rule out acute HIV
Rule out PEP eligibility
Assess adherence
Screen for STIs
What is your next step?

19. Post-exposure Prophylaxis (PEP)
Exposure within 72 hours and patient has not been adherent to PrEP for past 7 days
28 day course of ARVs, and then option to transition seamlessly to PrEP
There is no evidence that PEP “masks” seroconversion

20. What if my patient has a positive HIV test on PrEP?
Discontinue PrEP to avoid development of HIV resistance
Ensure patient is linked to an HIV-primary care provider for care and early initiation of ART
Contact local health department at

21. PrEP considerations for adolescents
“Currently the data on the efficacy and safety of PrEP for adolescents are insufficient. Therefore, the risks and benefits of PrEP for adolescents should be weighed carefully in the context of local laws and regulations about autonomy in health care decision-making by minors.”(CDC GLs, 2014)
Anticipatory Guidance: engage before risks occur
Adherence concerns
Confidentiality concerns  payment?
“possibility of bone or other toxicities among youth who are still growing”
Consider “the safety evidence available when TDF/FTC is used in treatment regimens for HIV-infected youth”
ATN 110 and 113
Adherence decreased as time between study visits increased (from monthly to quarterly) among 200 YMSM
Special considerations: perceived low HIV risk, inconsistent condom use, high STD rates in youth, declining sexual education/hiv prevention education, low HIV testing, homelessness, substance use
CA allows minors aged ≥12 years to “consent to medical care related to the prevention of a sexually transmitted disease”
Prevent parents from receiving information in explanation of benefits
7-14 days in advance: Myhealthmyinfo.org
May qualify for Medi-Cal Sensitive Services
Same day registration before visit is complete
DPH Emergency Youth PrEP Fund

22. Take home messages:
Take a thorough sexual history to identify patients who might benefit from PrEP.
Offer PrEP to patients identified as having risks for HIV.
Conduct an HIV test to confirm a patient is HIV negative before starting them on PrEP.
Follow-up with patients every 3 months for HIV/STD testing and 90-day PrEP refill.