#41 HIV, PrEP, and STI screening

May 29, 2017 | By Matthew Watto, MD

Prevent HIV infections with pre-exposure prophylaxis (PrEP), and learn to perform appropriate screening for sexually transmitted infections with tips from expert, Dr. Gina Simoncini, Associate Professor of Medicine from Temple University. Learn how to implement PrEP in your practice, plus tips on vegetable gardens, fellowships, and where to get the best samosas in this wide ranging discussion.

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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.

Goal: Learn to safely and appropriately prescribe PrEP for your patients at increased risk for HIV infection.

Learning objectives: by the end of this podcast listeners will:

1. Identify patients appropriate for pre-exposure prophylaxis
2. Discuss the evidence behind recommendations for PrEP
3. Describe the agents and regimens recommended for PrEP
4. Deploy a standardized approach to monitoring for HIV, STIs and renal function
5. Establish a multidisciplinary team to help implement PrEP in clinic

Disclosures:
Dr. Simoncini reports research support from Gilead Sciences (who makes Truvada).

Time Stamps
00:00 Intro
04:50 Rapid fire questions
16:23 Defining preexposure prophylaxis
18:50 Who benefits from PrEP
21:43 Case discussion
23:45 PrEP during pregnancy, breastfeeding
24:45 Baseline testing and STI screening before PrEP use
28:15 Counseling on adherence, side effects
31:25 Adverse effects of PrEP
34:00 Monitoring patients on PrEP
36:46 Collaborative practice
37:30 Discussion of high risk behaviors on PrEP
39:30 Does PrEP promote viral resistance?
41:51 Insurance reimbursement for PrEP
42:50 Take home points
44:24 Outro

Links from the show:

1. https://www.cdc.gov/hiv/risk/prep/index.html – CDC PrEP guidelines
2. http://www.nejm.org/doi/full/10.1056/NEJMoa1011205#t=article – IPERGAY
3. http://www.nejm.org/doi/full/10.1056/NEJMoa1506273#t=article – IPREX