PrEP : HIV Pre-exposure Prophylaxis

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Katherine Marx, MS, MPH, FNP-BC. June 2014. Disclosure. I, Katherine Marx, have no relevant financial, professional, or personal relationships to disclose.. Objectives. Know current US recommendations for . ID: 731611 Download Presentation

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PrEP : HIV Pre-exposure Prophylaxis




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Presentations text content in PrEP : HIV Pre-exposure Prophylaxis

Slide1

PrEP: HIV Pre-exposure Prophylaxis

Katherine Marx, MS, MPH, FNP-BC

June 2014

Slide2

Disclosure

I, Katherine Marx, have no relevant financial, professional, or personal relationships to disclose.

Slide3

Objectives

Know current US recommendations for PrEPIdentify candidates for PrEP

Learn about resources for providing

PrEP

Slide4

Combination HIV Prevention

Biomedical InterventionsBehavioral InterventionsStructural Interventions

Slide5

Biomedical Interventions

PrEPPost-exposure prophylaxisTreatment as preventionDiagnosis and treatment of sexually transmitted infections

Prevention of mother-to-child

t

ransmission of HIV

Contraception to prevent unplanned pregnancy among women with HIV

Voluntary male

c

ircumcision

Blood safety

Injection safety

Microbicides

Slide6

PrEP: Pre-exposure Prophylaxis

How does it work?Uninfected person takes antiretrovirals

May prevent replication of virus & infection

Daily adherence to TDF/FTC

Slide7

NRTI

s and NNRTI

s work here

http://

www.aidsinfo.nih.gov

/education-materials/fact-sheets/19/73/the-

hiv

-life-cycle

Slide8

June 2013

CDC Interim Guidance:

PrEP

for IDU

PrEP

Timeline

November 2010

iPrEx

January 2011

CDC Interim Guidance:

PrEP

for MSM

August 2012

TDF2

Partners

PrEP

August 2012

CDC Interim Guidance:

PrEP

for

heterosexuals

July 2012

FEM-

PrEP

June 2013

Bangkok TDF Study

July 2012

FDA Approval

TDF/FTC

PrEP

January 2014

NYS AIDS Institute

Guidance for

PrEP

May 2014US Public Health ServiceClinical Practice Guideline for PrEP

March 2013

VOICE

Slide9

PrEP Studies: HIV transmission risk lowest when participants took

PrEP consistently

STUDY

OVERALL

Reduction in risk of HIV infection

Detectable level of medication in the blood

Reduction in risk of HIV infection

iPrEx

44%

>90%

TDF2

62%

---

Partners

PrEP

75%

90%

BTS

49%

74%

Adapted from summary of research at http://www.cdc.gov/hiv/prevention/research/prep/

Slide10

Slide11

Slide12

PrEP Utilization

Rawlings K, Mera R,

Pechonkina

A, et al. Status of

Truvada

for HIV pre-exposure prophylaxis (

PrEP

) in the United States: an early drug utilization analysis. 53rd ICAAC. September 10-13, 2013. Denver. Abstract H-663a.

Female

Male

Slide13

PrEP: Candidates

Substantial risk of acquiring HIV infectionMen who have sex with men (MSM)HIV-positive sexual partner

Recent bacterial STI

High number of sex partners

History of inconsistent/no condom use

Commercial sex work

http://

www.cdc.gov

/

hiv

/

pdf

/guidelines/PrEPguidelines2014.pdf

Slide14

PrEP: Candidates

Substantial risk of acquiring HIV infectionTransgender individualsEngaging in high-risk sexual behaviors

www.hivguidelines.org

Slide15

Risk Behavior Assessment for MSM

In the past 6 months:

Have you had sex with men, women, or both?

(if men or both sexes)

How many men have you had sex with?

How many times did you have receptive anal sex (you were the bottom) with a man who was not wearing a condom?

How many of your male sex partners were HIV-positive?

(if any positive)

With these HIV-positive male partners, how many times did you have

insertive

anal sex (you were the top) without you wearing the condom?

Have you used methamphetamines (such as crystal or speed)?

http://

www.cdc.gov

/

hiv

/

pdf

/guidelines/PrEPguidelines2014.pdf

Slide16

PrEP: Candidates

Substantial risk of acquiring HIV infectionHeterosexual women and menHIV-positive sexual partner

Recent bacterial STI

High number of sex partners

History of inconsistent/no condom use

Commercial sex work

High-prevalence area or network

http://

www.cdc.gov

/

hiv

/

pdf

/guidelines/PrEPguidelines2014.pdf

Slide17

PrEP: Candidates

Substantial risk of acquiring HIV infectionInjection drug users (IDU)HIV-positive injecting partner

Sharing injection equipment

Recent drug treatment (but currently injecting)

http://

www.cdc.gov

/

hiv

/

pdf

/guidelines/PrEPguidelines2014.pdf

Slide18

PrEP vs. nPEP

Case #1:24 year old white MSM who presents 4 hours after unprotected receptive anal sex, for the first time, with his HIV-infected partner.

Slide19

nPEP

Non-occupational Post-exposure ProphylaxisHigh risk exposureAs soon as possible28 day course

Tenofovir

/

emtricitabine

+

raltegravir

www.hivguidelines.org

Slide20

PrEP vs. nPEP

Case #2:24 year old MSM on nPEP

, day 27/28. Struggles with consistent condom use and regularly has unprotected receptive anal intercourse with his HIV-infected partner.

Slide21

PrEP: Clinical Eligibility

Documented negative HIV test No signs/symptoms of acute HIV infection

Normal renal function

No contraindicated medications

Documented hepatitis B infection & vaccination status

http://

www.cdc.gov

/

hiv

/

pdf

/guidelines/PrEPguidelines2014.pdf

Slide22

PrEP: HIV Testing

Are signs/symptoms of acute HIV present now or in prior 4 weeks?

Option 1: retest antibody in one month

Option 2: HIV antibody/antigen assay

Option 3: HIV-1 viral load

http://

www.cdc.gov

/

hiv

/

pdf

/guidelines/PrEPguidelines2014.pdf

Slide23

Acute HIV Infection

SymptomsFeverFatigueMyalgia

Skin rash

Headache

Pharyngitis

Cervical Lymphadenopathy

Arthralgia

Night sweats

Diarrhea

Daar

ES,

Pilcher

CD, Hecht

FM.

Curr

Opin HIV AIDS. 2008;3(1):10-15.

Slide24

PrEP: Considerations

AgeReproductive planOsteopenia/osteoporosis

www.hivguidelines.org

Slide25

PrEP: Risk Reduction

Case #3:32 year old black female seeks pregnancy.

She is not infected with HIV.

Her partner is HIV-infected and not currently on antiretroviral treatment.

Slide26

Providing PrEP

Before starting

PrEP

:

Clinical eligibility

Educate

Side effects

Limitations

Daily adherence

Symptoms of

seroconversion

Monitoring schedule

Safety

Criteria for discontinuation

Partner information

Social history: housing, substance use, mental health, domestic violence

Every visit:

Assess adherence

Risk reduction counseling

Provide condoms

www.hivguidelines.org

Slide27

Providing PrEP

After confirmation of clinical eligibility:Prescribe no more than 90-day supply of

PrEP

Truvada

1 tablet PO daily

(

tenofovir

300mg +

emtricitabine

200mg)

Insurance prior approval

Truvada

for

PrEP

Medication Assistance Program

Every visit:

Assess adherence

Risk reduction counseling

Provide condoms

http://

www.cdc.gov

/

hiv

/pdf/guidelines/PrEPguidelines2014.pdf

Slide28

Providing PrEP

3-month visit:HIV testAssess for acute infection

Check for side effects

Pregnancy testing

Prescribe 90-day supply of medication

Every visit:

Assess adherence

Risk reduction counseling

Provide condoms

http://

www.cdc.gov

/

hiv

/

pdf

/guidelines/PrEPguidelines2014.pdf

Slide29

Providing PrEP

6-month

HIV test

STI test

Pregnancy test

Renal function

90 day prescription

9-month

HIV test

Pregnancy test

90 day prescription

12-month

HIV test

STI tests

Pregnancy test

Renal function

90 day prescription

Assess the need to continue

PrEP

Every visit:

Assess adherence

Risk reduction counseling

Provide condoms

http://

www.cdc.gov

/hiv/pdf/guidelines/PrEPguidelines2014.pdf

Slide30

Support Adherence

Develop trust, avoid judgmentPlanMonitor

Educate

Identify barriers

Assess for side effects

http://

www.cdc.gov

/

hiv

/

pdf

/guidelines/PrEPguidelines2014.pdf

Slide31

Discontinuing PrEP

Positive HIV resultAcute HIV signs or symptomsNon-adherence

Renal disease

Changed life situation: lower HIV risk

http://

www.cdc.gov

/

hiv

/

pdf

/guidelines/PrEPguidelines2014.pdf

Slide32

PrEP: Research

PrEP in the real worldIntermittent dosingNew medications

New formulations

Slide33

PrEP Summary

EffectiveFDA approvedWell-tolerated

However,

Short-term data only

Daily adherence required

Side effects

Drug resistance in acute infection

Could lead to fewer condoms being used

Cost

Logistics

Slide34

PrEP Resources

CDC: http://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf

NYSDOH AI:

http://www.hivguidelines.org/

PrEP

Watch/ AVAC:

http://www.prepwatch.org/

Slide35

Additional Resources

NY/NJ AETC PrEP Webinarshttp://nynjaetc.virtualforum.com/pif.asp?Prog_ID=14060902&securitycode=KXbFYh

http://nynjaetc.virtualforum.com/pif.asp?Prog_ID=14052303&securitycode=01r27E

http://nynjaetc.virtualforum.com/pif.asp?Prog_ID=14050908&securitycode=o9k2C2

Slide36

Katherine Marx, MS, MPH, FNP-BC


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