PREP

Question 1

What do you need to counsel patient about when starting PREp?

Answer 1

adherence - include leaflet
Importance of regular HIV test, STI screen and renal monitoring 
Discuss risk of decrease in bone density 
Importance of condoms
Referral as required -chemsex, alcohol 
Daily PREP/on demand 
Dosing schedule
Lead in times
Symptoms of seroconversion

Question 2

What is lead in time for anal sex?

Answer 2

Two tablets 2-24h before sex

Question 3

What is lead in time for vaginal sex?

Answer 3

7 days

Question 4

What are the recommendations for PREP In MSM?

Answer 4

Increase risk of HIV
Condomless sex in past 6m
Ongoing condomless anal sex
If condomless sex with HIV pos partner and not suppressed VL (<200)
Case by case basis

Question 5

What are the recommendations for offering PREP in heterosexuals?

Answer 5

Condomless sexwith partner who is HIV pos and not fully suppressed VL (<200)
Case by case

Question 6

Can TDF alone be offered to MSM?

Answer 6

No

Question 7

Can TDF be offered alone to heterosexual men/women if FTC contraindicated?

Answer 7

Yes

Question 8

Can PREP be given to a woman using DMPA?

Answer 8

Prep is likely to counteract an increase in HIV acquisition but women should be offered an alternative contraception if available

Question 9

Is PREP recommended in people who inject drugs?

Answer 9

Not where needle exchange /opiate substitution services available
Case by case

Question 10

Which other groups should PREP be offered to?

Answer 10

Trans women having condomless sex in previous 6m and ongoing risk

Question 11

Are there any interaction with PREP and masculinising or feminising hormones?

Answer 11

No

Question 12

Can on demand PREP be used for trans people?

Answer 12

Yes if they are having only anal sex

Question 13

What age can PREP be offered?

Answer 13

15 years old and above

Question 14

What to suggest if PREP for anal sex interrupted (TD-FTC) and less than 7 days

Answer 14

Restart PREP with single dose

Question 15

What do you need to advise about starting and stopping PREP for vaginal sex

Answer 15

Lead in 7 days and continue daily for 7 days after sex

Question 16

What do you suggest if woman unable to take PREP with 7 day lead in

Answer 16

Double dose (although evidence currently only supports this for anal sex)

Question 17

If IV drug users are using PREP- what should be recommended about starting and stopping PREP?

Answer 17

Lead in 7 days and continue daily for 7 days after sex

Question 18

What baseline testing is recommended prior to starting PREP?

Answer 18

Baseline HIV ag/ab serology
Can start same day if negative test on the day
If risk within 4 weeks - can check HIV VL
Hep B/Hep C serology
Baseline renal function (serum creatinine, eGFR and urinalysis)

Question 19

What to recommend about PREP if symptoms of seroconversion

Answer 19

Defer PREP until HIV RNA test available

Question 20

What recommendation should be made about use of PREP if Hepatitis B coinfection?

Answer 20

On demand PREP should not be used- daily dosing

Question 21

What egfr is recommended for starting TDF?

Answer 21

> 60 ml/min/1.73m2

Question 22

If egfr is >60 ml/min/1.73m2 and patient wants to start PREP what would you advise?

Answer 22

Renal advice/case by case basis

Question 23

What should you consider with regards to renal/bone side effects and PREP?

Answer 23

Through medical hx
Pre existing renal disease/risk factors
e.g. egfr <90 ml/min, >40 yo, hypertension, diabetes
Any nephrotoxic medications

Question 24

Can pregnant woman at risk of HIV acquisition use PREP?

Answer 24

Yes- discuss risks/benfits
They can continue PREP while pregnant/breast feeding
Report information about PREP in pregnancy to ARV Pregnancy Registry

Question 25

In which groups might 4 doses/week of PREP be effective?

Answer 25

MSM and trans women only

Question 26

How to take on demand PREP

Answer 26

Loading dose 2-24 h before sex
1 tablet 24 h after
1 tablet 48 h after

Question 27

Can on demand PREP dosing be offered to heterosexual men and women

Answer 27

No

Question 28

How much PREP can you prescribe?

Answer 28

90 days

f/u at 4 weeks

Question 29

What follow-up for PREP is recommended?

Answer 29

HIV testing every 3 months
If primary confirmed HIV- need baseline resistance testing
3 monthly STI screen
3 monthly Hep C in MSM/transwomen/others at risk
egfr- annual if >90 and <40 yo
6 monthly if egfr 60-90, aged >40 and risk factors for renal impairement
egfr <60 - renal input needed

Question 30

What should be advised to patients about PREP and bone health?

Answer 30

BMD risk reduction- 1.5-2% in hip and spine after 48 weeks (12 months) treatment
No routine monitoring of BMD if no other risk factors
If risk factors- FRAX

Question 31

How is national monitoring of PREP eligibility, uptake and duration monitored?

Answer 31

SHHAPT code- PREP sexual health and HIV activity property type

Question 32

How can patients source PREP?

Answer 32

Signpost to I want Prep Now if can’t access PREP on NHS
They offer support and advice and can source generic drugs as safely as possible
The product should originate from a manufacturer listed by the US FDA
Ensure it is labelled as Tenofovir and FTC
Advise to have regular STI screen and Hepatitis C if at risk, HIV testing and renal monitoring

Question 33

Which studies do we have for safety and efficacy of PREP in MSM

Answer 33

PROUD- RCT- effective in reducing HIV in 86% respectively
IPREX- effective in reducing HIV in 44% respectively
IPERGAY- 97% reduction in HIV transmission compared to placebo

Question 34

In which groups might you consider PREP (ie medium risk?)

Answer 34

Heterosexual black African
Recent migrants to the UK
Transwomen
IVDUs
CSW
Bacterial STI/HCV in pervious year
PEPSE in past year
Chemsex/group sex
Multiple partners with condomless sex

Question 35

PREP consultation- what to discuss?

Answer 35

HIV transmission
How PREP works
Side effects
adherence and efficacy
dosing schedules
Lead in time
STI/HIV testing
Websites
BAseline assessment - HIV/U+E (discuss renal function)
STI screen 
PT
Discuss risk of bone loss
Treatment -90 day supply
f/u 4 weeks (adherence/side effects)
f/u 3/12 - sexual/drug hx, STI screen/HIV test
Yearly U+E (unless >40, nephrotoxic drugs, hypertension, DM- then 6/12)