PREP Flashcards
Drugs in Prep
Tenofovir and Emtricitabine
TDF-FTC
Offer prep toβ¦
- Hiv neg MSM with condomless anal sex in past 6/12 and ongoing condomless sex
- hiv neg MSM condomless sex with HIV pos partner not suppressed on ART
- combination of risk factors
When can you consider Tenofovir alone prep?
Heterosexual men and women where FTC is contraindicated
Prep and breastfeeding/ pregnancy
All ok
V little found in breast milk
No congenital anomaly from TDF during pregnancy
Three specific drugs used in chemsex
1) methamphetamine (Crystal/meth/Tina)
2) mephedrone (meph, miaow miaow, m-cat)
3) GHB/GBL (G, Gina)
PWID and prep
Low hiv prevalence in PWID
Donβt give prep where needel exchange and opiate substitution is available and accessed
Chemsex - different and high risk of HIV. Give prep
Trans prep prescribing recommendations
- Daily prep to hiv neg trans women having condomless anal sex in past 6/12 and ongoing
- prep for trans women and men with positive hiv partner not on ART
- if trans and only having anal sex - can consider EBD
- discuss unknown efficacy for vaginal sex and prep
Considerations for young people and prep
No need for routine BMD scan - evidence is all returns to normal on stopping
Teenagers critical peak of bone mass
Fraser guidance etc
Anal sex prep regime
Double dose 2-24 hours before sex
Single dose at 24 and then 48 hours
Continue daily until 48hours post last sex
If taking prep for anal sex and interrupted then whatβs the advice
If less than 7 days since last dose- single dose to restart
If more than 7 days since last dose - double dose to restart. Consider need for pep
Vaginas sex and prep regime
Takes 7 days until working (still take double dose incase canβt wait 7/7) and then continue for 7/7 post last sexual risk
Prep regime for PWID
7 days to work, 7 days after last risk to stop
Population risk factors for HIV acquisition
Heterosexual black African men and women Recent migrant to UK Transwoman PWID Sex work/ transactional sex
Clinical indicators for increasing HIV risk
Rectal bacterial STI in past year
Baceterial STI or HCV in past year
Pepse in previous year (repeated courses particularly)
Sexual behaviours and risks for HIV acquisition
Condomless sex with unknown HIV status of partner (particularly if anal or multiple partners)
Condomless sex from high risk country
High risk behaviour - chemsex/ group sex
Reports anticipated high risk sex
Drug use risk factors for HIV
Sharing kit
Unsafe setting for injecting
No needle exchange or opiate sub programme
Sexual health autonomy risk factors for HIV
No option for condoms Coercive violent relationship Homelessness or precarious housing Sex exploration risk or trafficking Drug/alcohol/ mental health impact
WHO definition of hiv substantial risk of acquiring?
Incidence greater than 3 per 100 person years
Predictors of HIV infection associations
Concurrent rectal STI
2 or more condomless acts in past 90 days
Prev pep in past 90 days
Chemsex
What to cover in discussion re prep and educating patient
Hiv transmission Testing and window periods Side effects of prep Efficacy and adherence Regime Pep for risks Sti testing and prevention Resources I want prep now Referral for any support services e.g drugs
How to transition from pep to prep and testing times
Test after pep finishes (4 weeks)
Then test again 4 weeks after starting prep
Hiv testing required to start prep
Must have baseline 4th generation or negative result in past 4 weeks
Can do a poct and wait results (higher false positives and false neg in early infection)
What to send if starting prep and high risk exposure in past 4 weeks
Hiv viral load
Start prep if no Sx, negative poct and ongoing risk and then retest in 4/52
Symptoms of acute HIV infection
Commonly rash and fever
Also headache, malaise, arthralgia, sore throat
Risk factors for renal disease to consider
Nephrotoxic meds
>40 years old
Diabetic/HTN
Egfr when ok to start prep
> 60
If less than - renal consultant
Considerations if patient on prep and also chronic Hep B
Donβt suddenly stop as risk of rebound viraemia and hepatic flare - slowly with LFTs
Donβt give event based dosing
Vaccinate
Daily dosing - minimum no of tablets per week
4 at least ( do alternative days)
When to give pep after prep not used correctly?
Anal and vaginal
If less than 3 tablets taken in last 7 days or if last dose was more than 7 days ago
If 3 tablets taken in past 7/7 - just have single dose now and covered
If vaginal sex - give pep if less than 6 tablets in past 7/7 or more than 48hours since last dose
Follow up schedule for prep
1/12 - phone or text to check adherence/ ses
3/12 - hiv, sts, stis, Hep c
Annual egfr, creatinine if no renal concerns
Side effects of prep
Nausea Flatulence Abdo pain Dizziness Headache Most disappear in 1/12 Renal and bone longer term
What to discuss at prep first visit and to do
Prep Medical Hx Drug hx Risk assessment and prep eligibility Acute hiv infection (Sx in past 4/52?) Pepse Any HIV pos partners? Testing hx last 1 year Sex hx ans when last sex EBD vs daily Adherence Renal/ bone Results Follow up schedule Short term side effects
Baseline prep tests
Hiv 4th gen plus POCT for same day Sti screen Hep b and c screen for those at risk Serum creatinine, egfr and urinalysis Pt if needed Hep a vaccination
Quarterly visit prep
? Need to continue Adherence Risk reduction advise Improve adherence Rec drugs alcohol support Results Hiv/ Hep c sti screen Px for 90 days F/u 3/12 Annual bloods
If seroconversion on prep
Baseline resistance testing ASAP - check for mutations to prep
Consider drug levels
Public health questionnaire
If renal concerns then minimum testing frequency for hep c when on prep?
6monthly
No need for routine urinalysis at follow up if renal function ok and no additional risk factors as low PPV for proteinuria and raised creatinine
Bone risk and prep
Reduction in BMD of 1.5-2% at hip and spine after 48 weeks prep
No routine bone monitoring
If have osteoporosis consider vit d and ca
Use frax tool to indicate need for dexa
When to stop prep
Change in risk behaviour
Renal function <60 egfr
Poor adherence and no improvement with support ( risk of resistance)
Hiv pos
Always check for active hep b before stopping