1. PrEP Education and Counseling in a Title X Setting
Dominika Seidman, MD, MAS

2. Disclosures Successful Completion:
Contact hours will be prorated according to documented attendance. To receive contact hours, participants must complete and submit the on-line evaluation/request for credit form. CNE and CME certificates will be ed approximately 4 weeks after completion of the evaluation/request for credit form.
Commercial Support/Sponsorship:
There is no commercial support for this training.
Non-Endorsement of Products:
The University of Missouri-Kansas City School of Nursing and Health Studies, AAFP and the ANCC do not approve or endorse any commercial products associated with this activity.

3. Disclosures Conflict of Interest:
In accordance with continuing education guidelines, the speakers and planning committee members have disclosed commercial interests/financial relationships with companies whose products or services may be discussed during this program.
Speakers: Dominika Seidman has no personal conflicts of interest to report.
Planning Committee:
Katherine Atcheson, Angela Bolen, Sharon Colbert and Shelby Webb have nothing to disclose. Jacki Witt serves on the advisory panel for Afaxys (Resolved).
Acknowledgment of Funding:
This presentation was supported by Grant # 1 FPTPA from the United States Department of Health and Human Services (HHS), Office of the Assistant Secretary of Health (OASH), Office of Population Affairs (OPA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS, OASH, or OPA.

4. Disclosures Continuing Medical Education
This Live series activity, PrEP in Family Planning Project ECHO, from 08/07/ /18/2019, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Approved for 1 AAFP (1 Elective) credits.
Continuing Nursing Education The University of Missouri-Kansas City School of Nursing and Health Studies is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Each live webinar offers up to 1.0 contact hour for nurses.

5. Objectives
After attending this ECHO session, participants should be able to:
-Describe strategies to integrate education about PrEP into clinic visits
-Identify potential PrEP recipients in Title X settings
-Counsel individuals who may be interested in using PrEP

6. US Context
Women made up ~20% of new HIV diagnoses, and accounted for ~5% of PrEP users in 2016
Black women have ~16X lifetime risk of acquiring HIV compared to White women, while White women are 3-4X more likely to receive PrEP prescriptions than Black women
Women want integrated conversations about sexual and reproductive healthcare
Title X providers are uniquely qualified to integrate PrEP services into their work.
Bush,S. et al. HIV Drug Therapy 2016; Glasgow, Scotland
Smith DK. By race/ethnicity, Blacks have highest number needing PrEP in the United States, CROI 2018

7. CDC: Indications for PrEP in Women

8. Barriers to Disclosure at Screening
Stigma around sexual practices
Distrust of the medical system
Experiences of racism in medicine
Personal history of (other) trauma(s)
Low levels of PrEP awareness in women
Limited perceived vulnerability to HIV among women

9. Offering Universal Education About PrEP
We can talk to patients at:
Any HIV test
Any STI screen and/or treatment
Any sexual history taking
Who can talk about PrEP with patients?
Anyone! Share workloads, especially counseling, & use ready-made resources.

10. Talking About PrEP in a Family Planning Visit
What is PrEP?
Compare it to something familiar (birth control pills ~ PrEP; emergency contraception ~ PEP)
Who is PrEP for?
Everyone including:
Adolescents
Pregnant people & people trying to get pregnant
People who are breastfeeding
Transgender individuals
A pill you take every day to prevent HIV.
A pill you take every day to prevent HIV.
Everyone!

11. Talking About PrEP in a Family Planning Visit
Some key messages about PrEP include:
PrEP is effective. PrEP is safe.
PrEP has few side effects. PrEP only prevents HIV (not other STIs).

12. Ways to Talk About PrEP
PrEP is about staying healthy & building confidence.
Be transparent: this information may not be useful to a given individual right now, but it may be helpful later, or it may be helpful to a family member/friend/partner.
We are trying to get the word out about an exciting & important new HIV prevention method called PrEP. We’d love your help!

13. Integrating Conversations About Syphilis and PrEP
Provide information: data suggest that people diagnosed with syphilis have increased likelihood of acquiring HIV
Consider approaching syphilis diagnosis as an opportunity: treat syphilis and learn about/start HIV prevention methods like PrEP
Multiple visits related to syphilis treatment / followup testing = multiple visits to talk about PrEP and HIV prevention

14. More In-Depth Counseling Messages About PrEP
Daily adherence = effectiveness
>90% effective for vaginal exposures
Event-driven PrEP (taking PrEP only for a few doses around sex) is NOT recommended for cisgender women
Regular HIV testing is mandatory
PrEP does not prevent against other STIs
Safe with all methods of contraception, and in pregnancy & breastfeeding

15. Safety Profile and Side Effects of PrEP
Serious adverse events are rare
1/200 risk renal dysfunction
1-2% change in bone mineral density; no increased risk of fracture over 1-2 years; reversible after discontinuation
PrEP is well tolerated
Nausea in < 10% subjects; primarily during 1st month (PrEP “start-up” symptoms)
Risk of developing drug resistance is highest when PrEP is prescribed to individuals already infected with HIV
Overall risk of resistance 0.1%
CDC. Preexposure Prophylaxis for the Prevention of HIV Infection in the US: A Clinical Practice Guideline Fonner et al.
Oral pre-exposure prophylaxis (PrEP) for all populations: a systematic review and meta-analysis.

16. Counseling Pearls…That You Already Know
PrEP may not be for everyone, but comprehensive HIV education is for everyone
Shared decision-making to guide conversations
Trust women

17. Counseling About HIV Prevention Options
PEP
and/or
PrEP
Partner testing
Condoms
Changing type, frequency of sex
Treatment as prevention of partner living with
HIV
Screening & treating STIs

18. Prevention Access Campaign PreventionAccess.org

19. Shared Decision Making in HIV Prevention

21. Questions?
Feel free to contact me: