Pre-exposure prophylaxis (PrEP) counselling Flashcards
What are the indications for PrEP?
- Men who have sex with men (MSM) or trans women reporting condomless sex in the last 6 months or ongoing condomless anal sex
- Anyone reporting condomless sex with someone who is known to be HIV +ve, unless the partner has a viral load <200 copies/mL
What are the risk factors for contracting HIV?
- Reporting future anticipated high-risk sexual behaviour
- Bacterial rectal sexually transmitted infection (STI) or hepatitis C (HCV) in the previous year
- Use of post-exposure prophylaxis (PEP) in the previous year
- Feeling unable to negotiate and/or use condoms
- Condomless sex with high-risk populations
- Injecting recreational drug use/sharing drug-taking equipment
What are the contraindications to PrEP?
People who are HIV +ve (can cause resistance to medications used for treatment)
How would you explain PrEP to a patient?
PrEP stands for pre-exposure prophylaxis. It is a medication that you take before and after sex which can help prevent you from being infected with HIV.
It is a combination of 2 medications which stop the virus infecting your cells. We have been using these drugs to treat HIV for a long time.
Studies have shown that if PrEP is taken reliably, it reduces the chance of being infected with HIV via sexual intercourse by up to 99%.
What 2 drugs make up PrEP?
Tenofovir DF
Emtricitabine
How can PrEP be taken?
2 methods:
- Daily dosing
- Event-based dosing (before and after sex)
Describe daily dosing method of taking PreP
Daily dosing:
- Taking PrEP every say results in a consistent level of protection from HIV infection at all times if it is taken correctly
- Benefit: sexual encounters do not need to be planned for
Time to protection:
- anal sex: initial protection provided by taking 2 pills 2-24 hours before sex and then 1 subsequent pill at 24-48h after
- a daily pill from 72h onwards then provides future protection, so long as there is no break
- vaginal sex: the time to clinical protection is 7 days of daily dosing
Describe the event-based dosing method of taking PrEP.
- Involves taking PrEP before sex and after sex
- Appropriate for anal sex and men having insertive vaginal sex
- Contraindicated in anyone having receptive vaginal sex or with a current Hep B infection
How to take:
- 2 tablets between 2-24h before sex
- A single pill 24h after 1st dose
- Another pill 24h after 2nd dose
- If a patient is planning to have sex multiple times over a period of more than 24h, they should continues to take PrEP every 24h until 48h have passed since the last episode of sex
- If a patient plans to have sex less than a week after they last finished PrEP, they can take a single initial dose instead of a double dose
What are the side effects of PrEP?
- Nausea
- Headache
- GI disturbance
- Less common, more serious side effects include impaired kidney function (reversible), and a decrease in bone density
How would explain the monitoring required with taking PrEP to a patient?
- Before you start PrEP it is important we do some baseline blood tests to ensure that it is safe for you to take it
- If you start PrEP and already have HIV, it can lead to the virus becoming resistant to the medication
- We need to do a blood test to look for a virus called hepatitis B. If you were found to have hepatitis B, then event-based dosing wouldn’t be suitable for you, and we would also have to refer you to the liver team for treatment.
- If you do not have hepatitis B, we can offer you a vaccine against it to protect you int he future
- As PrEP can occasionally affect your kidney function, it is important that we know how well they are working today so we can quickly identify any deterioration in the future
- We recommend that everybody who is sexually active gets a regular sexual health screen every 3 months, especially if they are having condomless sex
With the daily dosing method, what information should you give to patients about missed pills?
- If one or two doses are missed, this is not an issue as long as it has been taken consistently for at least 7 days
- Repeatedly missed doses results in a decreased level of protection
- Studies show that if a patient misses 3 doses in a 1-week period, protection drops from 99% to 96%, this falls further to 76% if 5 pills are missed
- If a patient has missed >7 pills in a row they should restart with a double dose and then continue a single dose from the next day onwards
With the event-based dosing method, what information should you give to patients about missed pills?
- If the first double dose is forgotten before sex it should be taken immediately after and then a single pill continued daily
- The patient should also be advised to contact their local clinic or emergency department to discuss the need for post-exposure prophylaxis
What specific advice should you give to women taking PrEP?
- PrEP will not affect contraception and vice versa
- Studies have not shown any pregnancy complications from PrEP (but sample size was small - seek advice from doctor)
- Daily PrEP can be used safely when breastfeeding
What specific advice should you give to trans* and non-binary people taking PrEP?
- If having vaginal sex, then daily dosing is needed
- If only having anal sex then event-based dosing can also be used
- PrEP will not affect any hormone treatment being taken
How should you finish a ‘discussing PrEP consultation’?
“Before we finish I would like to check that we have been through everything you need. We have discussed how PrEP works, how to take it, what to do if you miss a dose, common side effects, and follow-up going forwards. Is there anything you feel we have missed? Or anything else you would like to ask?”
