PREP Flashcards
What do you need to counsel patient about when starting PREp?
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
What is lead in time for anal sex?
Two tablets 2-24h before sex
What is lead in time for vaginal sex?
7 days
What are the recommendations for PREP In MSM?
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
What are the recommendations for offering PREP in heterosexuals?
Condomless sexwith partner who is HIV pos and not fully suppressed VL (<200)
Case by case
Can TDF alone be offered to MSM?
No
Can TDF be offered alone to heterosexual men/women if FTC contraindicated?
Yes
Can PREP be given to a woman using DMPA?
Prep is likely to counteract an increase in HIV acquisition but women should be offered an alternative contraception if available
Is PREP recommended in people who inject drugs?
Not where needle exchange /opiate substitution services available
Case by case
Which other groups should PREP be offered to?
Trans women having condomless sex in previous 6m and ongoing risk
Are there any interaction with PREP and masculinising or feminising hormones?
No
Can on demand PREP be used for trans people?
Yes if they are having only anal sex
What age can PREP be offered?
15 years old and above
What to suggest if PREP for anal sex interrupted (TD-FTC) and less than 7 days
Restart PREP with single dose
What do you need to advise about starting and stopping PREP for vaginal sex
Lead in 7 days and continue daily for 7 days after sex
What do you suggest if woman unable to take PREP with 7 day lead in
Double dose (although evidence currently only supports this for anal sex)
If IV drug users are using PREP- what should be recommended about starting and stopping PREP?
Lead in 7 days and continue daily for 7 days after sex
What baseline testing is recommended prior to starting PREP?
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)
What to recommend about PREP if symptoms of seroconversion
Defer PREP until HIV RNA test available
What recommendation should be made about use of PREP if Hepatitis B coinfection?
On demand PREP should not be used- daily dosing
What egfr is recommended for starting TDF?
> 60 ml/min/1.73m2
If egfr is >60 ml/min/1.73m2 and patient wants to start PREP what would you advise?
Renal advice/case by case basis
What should you consider with regards to renal/bone side effects and PREP?
Through medical hx
Pre existing renal disease/risk factors
e.g. egfr <90 ml/min, >40 yo, hypertension, diabetes
Any nephrotoxic medications
Can pregnant woman at risk of HIV acquisition use PREP?
Yes- discuss risks/benfits
They can continue PREP while pregnant/breast feeding
Report information about PREP in pregnancy to ARV Pregnancy Registry
In which groups might 4 doses/week of PREP be effective?
MSM and trans women only
How to take on demand PREP
Loading dose 2-24 h before sex
1 tablet 24 h after
1 tablet 48 h after
Can on demand PREP dosing be offered to heterosexual men and women
No
How much PREP can you prescribe?
90 days
f/u at 4 weeks
What follow-up for PREP is recommended?
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
What should be advised to patients about PREP and bone health?
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
How is national monitoring of PREP eligibility, uptake and duration monitored?
SHHAPT code- PREP sexual health and HIV activity property type
How can patients source PREP?
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
Which studies do we have for safety and efficacy of PREP in MSM
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
In which groups might you consider PREP (ie medium risk?)
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
PREP consultation- what to discuss?
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)
