PrEP Case Consultation

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PrEP Case Consultation - Description

Susanne Doblecki-Lewis, 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 Download Presentation

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PrEP Case Consultation




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Presentations text content in PrEP Case Consultation

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, 2016

Slide2

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 2.0Using PrEP to Prevent Transmission

Slide4

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 Diseases

Nurse Practitioners & Physician Assistants in many settings

RNs (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 Clinics

Community Health Centers

Federally Qualified Health Centers

HIV-Treatment Centers

Slide7

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 hours

Slide9

PEP Implementation

PEP is time sensitiveNeed 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.pdf

Slide10

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 daysTenofovir/Emtricitabine/RaltegravirTenofovir/Emtricitabine/DolutegravirTenofovir/Emtricitabine/Darunavir/RitonavirRecheck HIV test4-6 weeks3 months6 months

http://

www.cdc.gov

/

hiv

/

pdf

/

programresources

/

cdc-hiv-npep-

guidelines.pdf

Slide12

How to Give nPEP

If possible, give a “Starter Pack” of 3-5 days of meds, or the entire 28 day courseThis requires supply of medication on hand in the clinic or pharmacyAdherence 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.pdf

Slide13

How to Pay for nPEP

Commercial insurance covers

nPEP

May have high copay

Need to communicate urgency by phone

Medicaid will cover

nPEP

Patient Assistance Programs, likely multiple

Good resource for process for PAPs for

nPEP

:

https

://

www.health.ny.gov

/diseases/aids/providers/standards/docs/

payment_options_npep.pdf

Slide14

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 indicated

Slide18

Start nPEP

Baseline rapid HIV test is negative

Start 3-drug

nPEP

HIV Ag/

Ab

test is

negative

Re-test at 4 weeks

Slide19

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.pdf

Slide20

How to Give PrEP?

Creatinine

(

CrCl

> 60 mg/dl)

Hepatitis B serology (vaccinate if

neg

)

P

regnancy test for women

Baseline HIV test

E

valuate for symptoms of acute HIV infection

Slide21

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.pdf

Slide22

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

unclear

7 days needed to achieve protective levels in rectal mucosa

21 days for women

Slide23

How to Follow a Patient on PrEP?

Quarterly check-ins for HIV testing, side effects, counseling, prescriptionCreatinine at 3 months & every 6 months if OKSTD testing every 6 months

http://

www.cdc.gov

/

hiv

/

pdf

/prepguidelines2014.pdf

Slide24

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

/


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