Sexual Health

Question 1

HIV pre-exposure prophylaxis is recommended for high risk patient groups.
Which patient groups are at risk of HIV infection?

Answer 1

1. Men who have sex with men (MSM)
2. Transgender and gender diverse people
3. Heterosexual people
4. People who inject drugs

eTG 2019

Question 2

Level of HIV risk is determined by the person’s (1) and (2).

Answer 2

(1) Recent risk of HIV exposure
(2) Sustained risk of HIV exposure

eTG 2019

Question 3

HIV PrEP is recommended for which groups?

Answer 3

High risk in the following:

1. Men who have sex with men (MSM)
2. Transgender and gender diverse people
3. Heterosexual people
4. People who inject drugs

eTG 2019

Question 4

Which patient groups would one consider HIV PrEP?

Answer 4

Medium risk in the following:

1. Men who have sex with men (MSM)
2. Transgender and gender diverse people
3. Heterosexual people

eTG 2019

Question 5

How would one diffferentiate between high and medium risk for Men who have sex with men (MSM)?

Answer 5

Both medium and high risk groups have the same sustained risk of HIV exposure: being likely to have multiple episodes of condomless anal intercourse with any casual male partner in the next 3 months

For high risk, any of the following recent risk of HIV exposure:

• at least one episode of condomless anal intercourse with a regular HIV-positive partner (not on treatment, or on treatment with a detectable viral load) in the last 3 months
• at least one episode of receptive condomless anal intercourse with any casual HIV-positive male partner or a male partner of unknown HIV status in the last 3 months
• a diagnosis of rectal infection with Neisseria gonorrhoeae, Chlamydia trachomatis or syphilis during the last 3 months or at screening for PrEP
• metamfetamine use in the last 3 months.

For medium risk, any of the following recent risk of HIV exposure:

• more than one episode of anal intercourse without proper condom use (eg condom slipped off or split) with a partner of unknown HIV status, or HIV-positive partner (not on treatment or on treatment with a detectable viral load) in the last 3 months
• men who are uncircumcised and have had more than one episode of insertive condomless anal intercourse with a partner of unknown HIV status, or HIV-positive partner (not on treatment or on treatment with a detectable viral load) in the last 3 months.

eTG 2019, ASHM

Question 6

How would one diffferentiate between high and medium risk for Transgender and gender diverse people?

Answer 6

Both medium and high risk groups have the same sustained risk of HIV exposure: being likely to have multiple episodes of condomless anal or vaginal intercourse with any casual male partnerin the next 3 months

For high risk, any of the following recent risk of HIV exposure:

• being a regular sexual partner of an HIV-positive person (not on treatment, or on treatment with a detectable viral load) with whom condoms have not been consistently used in the last 3 months
• at least one episode of receptive condomless intercourse with any casual HIV-positive partner or a male partner of unknown HIV status in the last 3 months
• diagnosed with rectal or vaginal infection with Neisseria gonorrhoeae, Chlamydia trachomatis or syphilis during the last 3 months or at screening for PrEP
• metamfetamine use in the last 3 months.

For medium risk, any of the following recent risk of HIV exposure:

• more than one episode of anal or vaginal intercourse without proper condom use (eg condom slipped off or split) with a partner of unknown HIV status, or HIV-positive partner (not on treatment, or on treatment with a detectable viral load) in the last 3 months
• people with an uncircumcised penis who have had more than one episode of insertive condomless anal intercourse with a partner of unknown HIV status, or HIV-positive partner (not on treatment, or on treatment with a detectable viral load) in the last 3 months.

eTG 2019, ASHM

Question 7

How would one diffferentiate between high and medium risk for heterosexual people?

Answer 7

High risk of HIV infection, defined as having both:

1) sustained risk of exposure to HIV—being likely to have multiple episodes of condomless anal or vaginal intercourse with any casual MSM partner in the next 3 months; and

2) recent risk of HIV exposure—any of the following:
- being a regular sexual partner of an HIV-positive person (not on treatment, or on treatment with a detectable viral load) with whom condoms have not been consistently used in the last 3 months
- at least one episode of receptive anal or vaginal condomless intercourse with any casual HIV-positive partner or a male homosexual or bisexual partner of unknown HIV status in the last 3 months.

Also, recommended to commence for Women with an HIV-positive male partner who are planning natural conception in the next 3 months

Medium risk of HIV infection, defined as having both:
- sustained risk of exposure to HIV—being likely to have multiple episodes of condomless anal or vaginal intercourse with a heterosexual partner (not known to be HIV positive but at high risk of being HIV positive) in the next 3 months; and

• recent risk of HIV exposure—at least one episode of condomless anal or vaginal intercourse with a heterosexual partner of unknown HIV status from a country with high HIV prevalence in the last 3 months.

eTG 2019, ASHM

Question 8

IVDU who are at high risk of HIV infection is defined as having both

Answer 8

1) sustained risk of exposure to HIV—any of the following:
being likely to share injecting equipment multiple times with an HIV-positive individual or a homosexual or bisexual man of unknown HIV status in the next 3 months
inadequate access to safe injecting equipment in the next 3 months, and

2) recent risk of HIV exposure—have shared injecting equipment with an HIV-positive individual or with a homosexual or bisexual man of unknown HIV status in the last 3 months.

eTG 2019, ASHM

Question 9

List 4 management steps prior to prescription of HIV PrEP

Answer 9

1) Perform baseline testing for HIV, hepatitis B and C virus, sexually transmitted infections (see Investigations for STIs), kidney function (including protein-to-creatinine ratio) and pregnancy (if applicable).
2) Provide advice about reducing the risk of HIV and sexually transmitted infections.
3) Assess the person’s need for HIV postexposure prophylaxis (PEP) if exposure to HIV may have occurred in the previous 72 hours (see Management of suspected or confirmed exposure to HIV).
4) Ensure the patient can attend for regular follow-up (eg at least every 3 months).

Note:

• HIV Ag/Ab test needs to be current (within past 7 days)
• Hepatitis C not usually tested unless HIV or intravenous drug use is present. However, it should also be tested prior to commencement of PrEP as an active infection would require treatment in consultation with a hepatologist.
• tenofovir/emtricitabine is well tolerated but can result in reversible small reductions in renal function, especially in people aged > 50yo.

eTG 2019, Check Sexual Health 2019