#417 USPSTF Update: PrEP for HIV Prevention with Dr. John Wong MD

November 22, 2023 | By Beth “Garbs” Gasperlin

Audio

Video

Transcripts available via YouTube

Become a pro on pre-exposure prophylaxis!

Review the updated 2023 United States Preventive Task Force (USPSTF) guidelines on PrEP for HIV Prevention with Dr. John Wong. 

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Show Segments

• Intro
• What is PrEP?
• USPSTF PrEP for HIV Prophylaxis recommendations
• Defining Increased Risk for HIV
• Counseling pearls
• Types of PrEP, considerations about choice of PrEP
• Talking about Safer Sex practices, HIV and STI screening on PrEP
• Recap; outro

USPSTF PrEP Pearls

1. It is estimated that 1 in 7 of individuals with HIV are unaware of their infection (KFF 2023).  The USPSTF recommends screening for HIV in those between the ages of 15 and 65 as well as in anyone who is at increased risk, and in all pregnant persons (USPSTF 2019). 
2. The USPSTF recommends that clinicians prescribe preexposure prophylaxis (PrEP) using effective antiretroviral therapy to persons who are at increased risk of HIV acquisition to decrease the risk of acquiring HIV. 
3. There are two oral versions and an injectable form of PrEP. Both forms of medication are safe and effective, but now prescribers have additional options that can be more appropriately tailored to patient preferences and lifestyle. The oral options are emtricitabine/tenofovir disoproxil fumarate, abbreviated as TDF-FTC, brand name: Truvada,  and emtricitabine/tenofovir alafenamide, abbreviated as TAF-FTC, brand name: Descovy. The injection version is cabotegravir extended-release suspension, brand name: Apretude.
4. TAF-FTC (Descovy) is not approved for recipients of vaginal sex. 
5. It is more patient-centered to use the phrase ‘increased risk’ as opposed to ‘high risk.’

USPSTF PrEP – Show Notes

HIV remains an important health concern across the globe. In 2020, there were over 30,000 new cases of HIV diagnosed in the United States (CDC 2022). There are 1.2 million individuals living with HIV in the United States (CDC 2019). It is estimated that 1 in 7 of individuals with HIV are unaware of their infection (KFF 2023).  The USPSTF recommends screening for HIV in those between the ages of 15 and 65, as well as in anyone who is at increased risk, and in all pregnant persons (USPSTF 2019). 

USPSTF Recommendations on PrEP 

​​The USPSTF recommends that clinicians prescribe preexposure prophylaxis (PrEP) using effective antiretroviral therapy to persons who are at increased risk of HIV acquisition to decrease the risk of acquiring HIV. 

What is PrEP?

PrEP stands for pre-exposure prophylaxis. It involves taking medication to prevent getting HIV infection. The USPSTF recommends that clinicians prescribe preexposure prophylaxis using effective antiretroviral therapy to persons who are at increased risk of HIV acquisition to decrease the risk of acquiring HIV. 

There are two oral versions and an injectable form. Both forms of medication are safe and effective, but now prescribers have additional options that can be more appropriately tailored to patient preferences and lifestyle. The oral options are emtricitabine/tenofovir disoproxil fumarate, abbreviated as TDF-FTC, brand name: Truvada and emtricitabine/tenofovir alafenamide, abbreviated as TAF-FTC, brand name: Descovy. The injection version is cabotegravir extended-release suspension, brand name: Apretude.  Patients must weigh at least 77lb (35kg) to receive PrEP.  TAF-FTC (Descovy) is not approved for recipients of vaginal sex. 

Prior to initiation, patients should receive testing for HIV (USPSTF 2023). If they have received oral PrEP or post-exposure prophylaxis in the past 3 months, or a cabotegravir injection in the past 12 months, they should be tested with an HIV antigen-antibody assay as well as HIV-1 RNA assay. If they have not, an HIV antigen-antibody assay is sufficient (CDC 2021). Other tests including baseline kidney function and hepatitis B serologies should be obtained as well in PrEP containing tenofovir (TDF/FTC or TAF/FTC)(USPSTF 2023). It is also recommended that testing for other STIs and pregnancy testing (when appropriate) be conducted prior to initiating PrEP 

and lipid profile testing is recommended prior to initiating TAF/FTC. Patients receiving PrEP should be screened every 2-3 months for HIV and at regular intervals for other STIs based upon their individual risk factors (USPSTF 2023).  Pharmacokinetic data suggests PrEP with TDF-FTC reaches its maximum concentrations in peripheral blood and rectal tissue after 7 days, and in cervicovaginal tissue after 20 days (USPSTF 2023, CDC 2021). 

Defining increased risk for HIV

Some factors that convey increased risk of HIV can come from having sexual intercourse with a person who has HIV infection, not using condoms consistently with sexual intercourse (taking into account a person’s number of partners, and whether their partner(s) are in a group with a higher prevalence of HIV), history of a bacterial STI in the past 6 months, and sharing needles or syringes.  (Note: we emphasize that it is more patient-centered to use the phrase ‘increased risk’ as opposed to ‘high risk’). PrEP is underprescribed, although it can be challenging to quantify. Our failure to prescribe PrEP is also exacerbating disparities in health. Additionally, patients may ask for PrEP but not want to disclose why they are requesting it as it involves disclosure of private topics so we should also be sensitive to that. Taking a sexual history can be challenging, try to normalize it by standardizing your approach. Check out this CDC guide for tips and tricks on taking a thorough sexual history. 

Links

1. USPSTF Recommendations on PrEP
2. USPSTF Discussion Guide on PrEP
3. CDC Guidance on HIV testing, prevention, and care
4. Task Force Prevention App

Goal

Listeners will review the updated USPSTF guidelines on PrEP. 

Learning objectives

After listening to this episode listeners will…

1. Review the updated USPSTF guidelines for PrEP.
2. Feel more comfortable integrating PrEP prescriptions into their practices for the appropriate patient population.

Disclosures

Dr. Wong reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Garbitelli BC, Wong J, Williams PN, Watto MF. “#417 USPSTF Update: PrEP for HIV Prevention with Dr. John Wong”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast November 22, 2023.