PEP/PrEP Flashcards by Harriett L-C

Baseline investigations in 1st PEP visit?

GC/C4, HIV (PoC and serum), STS, Hep B unless immune, hep c if indicated, PT, POC, udip, U&E, LFT

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First line therapy for PEP in UK?

tenofovir disoproxil 245mg/emtricitabine 200mg fixed dose combination plus raltegravir 1200mg once daily for 28 days

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First line PEP in uk if pregnant?

tenofovir disoproxil 245mg/emtricitabine 200mg fixed dose combination plus raltegravir 400mg BD for 28 days (can start with 600mg BD if needed to avoid delay starting)

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Medication interactions to tell a patient about on PEP?

Antacids (containing aluminium, magnesium or calcium), multivitamins and iron supplements
38.

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If further high risk SI whilst on PEP what do you advise the patient?

> 48hr pep remaining continue. <48hrs pep remaining; anal si extra 48hrs PEP, vaginal SI 7/7 extra.

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How long after completing prep should a follow up HIV test be taken?

45days (73 days after exposure).

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Missed doses of PEP what do you advise?

if you forget to take a dose, take it as soon as you remember it. However, if it is time for your next dose, skip the missed dose and go back to your regular schedule. Do not take a double dose to make up for a forgotten dose. If more than 48 hours has elapsed since the last dose then discontinue PEP.

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If using dolutegravir-based PEP what duration of missed doses should PEP be discontinued?

> 72 hours has elapsed since the last dose then dolutegravir-based PEP should be discontinued.

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SEs of PEP?

N+V, diarrhoea, insomnia, reduced appetite, rhabdomyolysis, renal failure

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risk of transmission from receptive condomless anal sex if receiving SI from a HIV+ve person not on ART if ejaculates?

1/65

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risk of HIV transmission from receptive condomless anal sex if receiving SI from a HIV+ve person not on ART if does NOT ejaculate?

1/170

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Risk of HIV transmission from receptive condomless anal sex if receiving SI from a HIV+ve person not on ART regardless of ejaculation?

1/90

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Risk of HIV transmission from insertive condomless anal SI regardless of circumcision from a HIV+ve person not on ART?

1/666

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Risk of HIV transmission from insertive condomless anal SI if circumcised from a HIV+ve person not on ART?

1/909

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Risk of HIV transmission from insertive condomless anal SI if NOT circumcised from a HIV+ve person not on ART?

1/161

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Risk of HIV transmission from receptive condomless vaginal SI from a HIV+ve person not on ART?

1/1000

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Risk of HIV transmission from insertive condomless vaginal SI from a HIV+ve person not on ART?

1/1219

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How do you calculate the Risk of HIV transmission?

Risk of HIV transmission = risk that source is HIV positive with a detectable HIV viral load x risk per exposure

Under the 2021 PEP guidelines when is pep recommended if SI have taken place with someone who is known HIV+ve not on tx or not undetectable?

Receptive/insertive anal sex and receptive vaginal sex.

Consider with insertive vaginal.

Under the 2021 PEP guidelines when is pep recommended if SI have taken place with someone who is of unknown HIV status?

Assess if from high risk group (IVDU/African/MSM) if low risk not recommended if high risk offer for receptive anal sex, consider for insertive anal sex and generally not recommended for receptive vaginal sex.

Option for someone requiring PEP with eGFR for 40?

Descovy and a third agent, the agent depends on the dose of descovy. Descovy 200mg/25mg should be prescribed with dolutegravir or raltegravir. Descovy 200mg/10mg should be prescribed with the protease inhibitors darunavir/ritonavir and atazanavir/ritonavir.

Items to discuss with individual commencing PEP?

The rationale for PEP
The lack of conclusive data for the efficacy of PEP
Start PEP as soon as possible and importance of adherence to optimise efficacy
The potential side-effects of PEP
Drug interactions including over the counter drugs such as multivitamins/antacids/iron
Emergency contraception (if appropriate)
Seek urgent medical attention if they develop symptoms of possible seroconversion
The arrangement for early follow-up with either an occupational health or HIV/GU medicine clinic
Verbal consent and HIV test (4th generation laboratory test)
The need to continue PEP for 28 days if the baseline result is negative
The need to have a follow-up HIV test a minimum of 45 days after completion of the PEP course – this is a minimum of 10.5 weeks post-exposure if the 28 days course is completed
The need to use condoms until the follow-up HIV testing is negative
Coping strategies, assessment of vulnerabilities and social support
For patients concerned about sexual risk-taking, appropriate advice and/or signposting should be provided according to local pathways including for PrEP

Follow up schedule for PEP?

Baseline and issue 28 day supply, see day 7 if hep b vaccine required, STI screen 2/52 or combine STI screen with 3rd hep b if required (day 21) . HIV day 73. STS 3/12 and hep screen, check immunity to hep b if <10 booster, if >10 boost 1 year, hep C 6/12 and B if <10at 12/52 screen. Hep B booster vaccine 12/12

For women <6/40 gestation which PEP agent should be avoided?

Dolutegravir

For women using PrEP when should PEP be considered?

PEP should be considered if more than 48 hours have elapsed since last dosing or if fewer than six tablets have been taken within the previous 7 days.

For msm using PrEP when should PEP be considered?

people on daily PrEP, where fewer than 4 pills have been taken in the last 7 days. Or for people on event-based PrEP, PEP is indicated where PrEP has not been taken as recommended.

Sings/symptoms of seroconversion on PEP?

Flu-like illness or rash, general malaise.

HIV+ve test after pep have been started stop/continue?

Continue pending HIV physician r/v

A woman is taking pop for contraception and required PEP, she is suitable for Truvada/raltegrivir – what advice do you need to give her regarding the effect on pep on her contraception?

There is no interaction, the pep and all contraception will work effectively.

Dose of PrEP for event based anal sex?

double dose of TDF-FTC 2–24 hours before sex and stopping with a single tablet taken at 24 hours and again at 48 hours after the first dose

Dose schedule of PrEP for event based vaginal sex?

One daily for 7 days before event and 7 days after, if unable to do 7 days before can double dose 1st day but evidence is from anal sex.

When to offer PEP to MSM having high risk condomless anal SI using PrEP?

< 3 doses in 7 days or > 7/7 since last dose.

Dose schedule for anal sex continuous PreP use?

Double dose of TDF-FTC 2–24 hours before sex and continue once daily until wanting to stop. To stop need to use until 48hrs post last risk event

When to offer pep to people using PrEP for vaginal/front sex?

<6 tables in 7 days leading up o or following risk event

Youngest age PrEP should be offered under guidelines in uk?

15yo

Renal monitoring for prep if eGRF 60-89?

Baseline and 6 monthly

Renal monitoring if eGFR >90 in prep?

Baseline and annual

Renal monitoring if PrEP user has eGFR of 45?

Case by case decision to initiated and continue, renal input.

A 21yo MSM attends seeking PrEP, he has had 7 partners for receptive and insertive condomless anal sex in the past 6 months and declines to use condoms. You give him information and take initial baseline investigations – the urine dip shows 1+ proteinurea, what is the next investigation required for him?

Urine PCR and can start prep whilst awaiting ix.

How often should renal monitoring be offered to a 45yo MSM on prep?

Baseline and every 6/12

Can people on PEP start PrEP immediately?

Yes, should have HIV test 45 days after finishing PEP and 45 days after starting PrEP then 3/12 follow up as usual.

Initiation visit for prep – what to cover?

Eligibility, PMHx and medications (esp bone/renal), sexual hx and STI risk, efficacy (86-96% reduction in anal SI HIV acquisition and taken according to instructions, the rest is less evidence), ways to take (EBD, 4 x weekly or continuous), time to effect (2 tablets 2-48hrs for anal, 7 days for vaginal), adherence and missed doses and when to consider PEPSE (anal: 3 or less tablets in 7/7 or >7/7 since last dose before or after event, vaginal; 6 or less doses in 7 days before or after event) seroconversion signs (flu/rash), side effects (GI upset, muscle aches), complications (renal toxicity, BMD reduction 1.5-2% b 48 months), safer sex/risk reduction. Baseline STI screen, Hep B status if not known immune, Hep C if risk, Udip (is 1+ proteinurea urine PCR), U&E, hep b and HPV vaccine if needed. PT if indicated. 90 day supply.

Follow up visits and content of visit for PrEP?

1/12 email/phone check in. Then every 3/12 STI screen, assess need and eligibility, ensure aware for the doses/adherence, risk reduction, PT if indicated and further 90 day supply