Susanne DobleckiLewis MD Associate Professor of Clinical Medicine Division of Infectious Diseases University of Miami Miller School of Medicine November 30 2016 Biomedical HIV Prevention ID: 612188
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Slide1
PrEP Case Consultation
Susanne Doblecki-Lewis, MD
Associate Professor of Clinical Medicine
Division of Infectious Diseases
University of Miami Miller School of Medicine
November 30, 2016Slide2
Biomedical HIV Prevention
…
that Works
Prior to exposure
Time of transmission
After infection
PrEP
PEP
ART Slide3
McCormack S, et al. Lancet. 2016 Jan 2; 387(10013); 53-60;
Molina JM, et al. N
Engl
J Med. 2015 Dec 3; (373)2237-2246;Baeten J, et al. CROI 2015 Feb 23-26; abstract 24.
Where are We Now - Prevention 2.0
Using PrEP to Prevent TransmissionSlide4
PrEP Use Has Escalated Quickly
Data from: Rawlings
K et al. (
McCallister
S presenting)
FTC/TDF (Truvada) for HIV pre-exposure prophylaxis (PrEP) utilization in the United States: 2013-2015. 21st International AIDS Conference, Durban, abstract TUAX0105LB, 2016.Slide5
A Variety of Providers are Involved in PrEP Care
Physician providers: Family Medicine, Internal Medicine, Pediatrics, Ob/
Gyn
, Infectious DiseasesNurse Practitioners & Physician Assistants in many settingsRNs (100% efficacy in SF project with 700 men)Pharmacists (Seattle project)Slide6
PrEP is Prescribed in a
Variety of Settings
Municipal STD Clinics
Sexual Health and Wellness ClinicsCommunity Health CentersFederally Qualified Health Centers
HIV-Treatment CentersSlide7
Some Questions for Today
How to choose
nPEP
or PrEP?How to transition from nPEP to PrEP?How to pay for PrEP?Slide8
Prior to exposure
Time of transmission
After infection
Biomedical HIV Prevention
PrEP
PEP
ART
72 hoursSlide9
PEP Implementation
PEP is
time sensitive
Need to begin medication ASAP, <72 hoursImportant to get baseline testing for HIV, also HBV and HCV, STIsPreferably HIV Ag/Ab test if available
http://
www.cdc.gov/hiv/pdf/programresources/cdc-hiv-npep-guidelines.pdfSlide10
HIV
Testing
and
Detection of
HIV
http://www.rnceus.com/fl2hiv/test2.
html (accessed Nov 2016)Slide11
PEP –
What to Give
Give 3 drugs for 28 days
Tenofovir/Emtricitabine/RaltegravirTenofovir/Emtricitabine/Dolutegravir
Tenofovir/Emtricitabine/Darunavir/RitonavirRecheck HIV test
4-6 weeks3 months6 monthshttp://www.cdc.gov
/hiv/pdf/programresources/cdc-hiv-npep-guidelines.pdfSlide12
How to Give nPEP
If possible, give a “Starter Pack” of 3-5 days of meds, or the entire 28 day course
This requires supply of medication on hand in the clinic or pharmacy
Adherence may be better when whole 28 day course is givenTwo drug nPEP is not recommended in current guidelines
http://
www.cdc.gov/hiv/pdf/programresources/cdc-hiv-npep-guidelines.pdfSlide13
How to Pay for nPEP
Commercial insurance covers
nPEP
May have high copayNeed to communicate urgency by phoneMedicaid will cover nPEP
Patient Assistance Programs, likely multipleGood resource for process for PAPs for nPEP
:https://www.health.ny.gov/diseases/aids/providers/standards/docs/
payment_options_npep.pdfSlide14
Case
A 33 year old man presents 24 hours after an episode of condomless receptive anal intercourse with a man who he subsequently learned was HIV positive.
He states that he has had 10 partners in the last 6 months and uses condoms inconsistently.
He has a history of rectal gonorrhea and secondary syphilis within the last year.Slide15
Questions
Is he a good candidate for
nPEP
?What about PrEP?Slide16
Source: http://
www.cdc.gov
/
hiv/policies/law/risk.html Slide17
This is a good candidate for PrEP due to repeated exposure (not just one episode)
However, had a high risk exposure within last 72 hours, so
nPEP
is indicatedSlide18
Start nPEP
Baseline rapid HIV test is negative
Start 3-drug
nPEPHIV Ag/Ab test is negative
Re-test at 4 weeksSlide19
4 Week Post-Exposure
HIV Ag/
Ab
repeat test is negativeCan transition directly to PrEP without gap
http://www.cdc.gov/
hiv/pdf/programresources/cdc-hiv-npep-guidelines.pdfSlide20
How to Give PrEP?
Creatinine
(
CrCl > 60 mg/dl)Hepatitis B serology (vaccinate if neg)Pregnancy test for women
Baseline HIV testEvaluate for symptoms of acute HIV infectionSlide21
What to Prescribe?
Tenofovir
/Emtricitabine (
Truvada®) is the only FDA approved drug for PrEPOne tablet daily is the only approved dosing strategyPre/Post Coital dosing is NOT recommendedPrescribe up to a 90 day supply
http://
www.cdc.gov/hiv/pdf/prepguidelines2014.pdfSlide22
Side Effects & What to Expect
Side-effects are generally minimal
Occasional GI upset that usually resolves in 1-2 weeks
Renal dysfunction is rare and reverses with discontinuation. Bone mineral density decrease may occur but clinical significance is unclear7 days needed to achieve protective levels in rectal mucosa
21 days for womenSlide23
How to Follow a Patient on PrEP?
Quarterly check-ins for HIV testing, side effects, counseling, prescription
Creatinine
at 3 months & every 6 months if OKSTD testing every 6 months
http://www.cdc.gov/hiv/
pdf/prepguidelines2014.pdfSlide24
www.projectinform.org/pre-chart
(in English and Spanish)Slide25
Thanks for Attending
Guidelines are available to answer many questions:
http://www.cdc.gov/hiv/pdf
/prepguidelines2014.pdf
http://www.hivguidelines.org/
PrEPline 855-448-7737 at the National Clinician Consultation Center http://nccc.ucsf.edu/clinician- consultation/prep-pre-exposure-prophylaxis/