HIV Prevention Flashcards
What can be said about individuals on ART with an undetectable viral load and transmission?
individuals with HIV who are on ART and maintain an undetectable VL cannot sexually transmit the virus to others, and are less likely to transmit via vertical transmission or with contaminated drug paraphernalia or hygiene items
What is PrEP?
an HIV prevention strategy to reduce the risk of acquiring HIV
taken by HIV negative individuals considered at risk of infection
Which agents are used for PrEP?
Truvada (TDF + emtricitabine) 1 tab daily
or
Descovy (TAF + emtricitabine)
How effective is PrEP?
reduces the risk of acquiring sexually transmitted HIV by more than 90% if taken as prescribed and by at least 74% among PWID
What is the key with PrEP?
adherence
Who is at risk of acquiring HIV and may benefit from PrEP?
MSM and transgender women engaging in condomless sex within the last 6 months who have any of the following:
-syphilis or rectal STI, recurrent use of PEP, ongoing relationship with HIV+ partner with risk of transmissible HIV, high incidence risk score
heterosexual exposure
-serodiscordant couples engaging in condomless sex where HIV+ partner has significant risk of transmitting to partner
PWID exposure
-sharing drug paraphernalia with a person with non-negligible risk of HIV infection
When is PrEP not recommended?
stable, closed relationship with negligible risk of transmission of HIV
Which PrEP regimen is generally not covered?
Descovy
When might Descovy be used for PrEP?
those with renal impairment
What is the “on demand” Truvada regimen for PrEP?
2 pills 2-24 hrs prior to first sexual exposure followed by 1 pill daily until 48 hrs after last sexual activity
-trials only support use in MSM
What are the baseline investigations done for PrEP?
HIV status
HBV A/B/C status
baseline STIs
pregnancy
CBC, renal panel, urinalysis
comorbidities: renal dysfunction, mental health, SUD
vaccination status
What is a contraindication to PrEP?
HIV +
Which patients is Truvada approved for as PrEP?
MSM, TGW, and heterosexuals for OD regimen
off-label: PWID for OD regimen
off-label: MSM for on-demand regimen
True or false: Truvada is safe in pregnancy and lactation
true
What are contraindications for Truvada?
HIV+
eGFR < 60 ml/min
What are some medications on the horizon for PrEP?
long-acting cabotegravir for injection
dapivirine silicone vaginal ring
What is the efficacy of the cabotegravir injection for PrEP?
promising trial evidence - superior to oral Truvada
-sexual risk: MSM, TGW, cisgender men & women
True or false: cabotegravir injection is approved in Canada for PrEP
false
likely to be approved this year
What are the limitations to using cabotegravir injection for PrEP?
access to injection
$$$
insufficient data to recommend in pregnancy currently
unknown reduction in PWID
risk of resistance if pt d/c then exposed to HIV
What is the efficacy of the dapivirine silicone vaginal ring for PrEP?
promising trial evidence - 50% reduction vs placebo
During which phases of pregnancy are pregnant women at an increased risk of acquiring HIV?
conception phase
pregnancy
early postpartum
incidence of HIV during pregnancy 2-6x greater than non-pregnant counterparts
How much is the risk of vertical transmission increased in women HIV+ during pregnancy?
9-15x
Which regimen is approved for PrEP in pregnancy and lactation?
Truvada once daily
What is critical with PrEP use in pregnancy?
adherence
-6 to 7 doses/week for optimal [ ] in vaginal and cervical tissues, especially in 2nd and 3rd trimester due to increased Vd
When should PrEP not be used in pregnancy?
same as non-pregnant population
-unknown HIV status, HIV+, CrCl < 60
Who can prescribe PrEP?
any physician, NP, or pharmacist with a collaborative prescribing agreement can prescribe PrEP
Describe proper client PrEP education.
benefits, benefits, benefits!
-if taken daily, can reduce HIV acquisition by over 90% via sexual exposure and > 74% of PWID
adherence is vital for effectiveness and needs to be stressed at baseline and review at subsequent visits
-OD PrEP studies have shown in MSM –> 4 tabs/wk was enough to provide protection against transmission
it utilizing PrEP on demand –> provide instructions
7 days is required to meet effective [ ] (in anal and vaginal tissues) when taken OD (controversy if takes 7-20 days in cervicovaginal tissue)
PrEP does not prevent other STBBIs/STIs
side effect expectation and management –> improve adherence
Describe proper PrEP follow up.
at 1 month, then every 3 months:
-review recent blood work
-assess for ongoing indication
-ongoing exposure
-HIV status negative
-if receiving on-demand –> indication to change to OD?
-discuss adherence
-assess tolerability
Describe proper discontinuation of PrEP.
in MSM or TGW:
-d/c 2-28 days after last exposure
heterosexuals or PWID:
-d/c 28 days after last exposure
on demand:
-take last tablet 48 hours after last exposure
recommend to rpt HIV serology 8-12 weeks after d/c
What is PEP?
post-exposure prophylaxis
-involves the use of HIV medications in an HIV negative person who may have been exposed to HIV to prevent transmission
What is key with PEP?
should start as soon as possible
-must be started within 72 hours of exposure
Where should a person present in order to access PEP?
any emergency department
-emerg physician will assess risk of exposure and need for PEP
What is included in the adult PEP kit in SK?
5 day supply of:
-Truvada one tablet once daily AND
-dolutegravir 50 mg one tablet once daily
intent is to give pt a chance to get drug coverage in place and take the prescription to be filled
True or false: there are pre-assembled peds PEP kits in SK
false
assembled on an as needed basis
What is the duration of treatment for PEP?
28 days in total
Describe proper PEP follow up.
all clients should receive baseline HIV test
client should receive HIV test at:
-4-6 weeks post-exposure
-3 months post-exposure
-6 months post-exposure
assess client for switch to PrEP following completion of PEP, should they have ongoing risk factors
