Transcript

Dr. Frank Domino:

Dan is here for a follow up of his hypertension, that is well-controlled on hydrochlorothiazide. Dan's social history is significant for having sex with men but not having a consistent partner. Last year, he developed chlamydia, which has him using condoms, "a little bit more often than before", but still very inconsistently. He asks about being given a pill to help prevent him from catching HIV.

Hi, this is Frank Domino, family physician and Professor in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School. And joining me to discuss pre-exposure prophylaxis for the prevention of HIV is Dr Jill Terrien, Director of Nurse Practitioner Programs in the Graduate School of Nursing at the University of Massachusetts Medical School. Thanks for coming in Gil.

Jill Terrien:

Thank you, Frank. This is a great topic and I'd like to know what are these new recommendations say about using PrEP?

Dr. Domino:

So the US Preventive Services Task Force issued a draft grade A recommendation supporting the use of pre-exposure prophylaxis. So a few definitions, a draft recommendation states that they found excellent evidence to support the use of this medication, and they're proposing it for comment across the internet. So the draft component, is that it's offering the opportunity for those in the audience to make comment about the pros and cons, but giving it an A, recommendation is quite remarkable. They found really quite good evidence that we should consider using pre-exposure prophylaxis medication.

The people who should be receiving it are men who have sex with men, are sexually active and have one of the following; an HIV positive partner, having had a recent exposure to syphilis, gonorrhea or chlamydia, or report inconsistent condom use with anal sex. They also recommend it for it sexually active heterosexual patients who have a partner who's HIV positive, have inconsistent condom use during high-risk exposures or have recently been diagnosed with an STI, like syphilis, gonorrhea or chlamydia. And finally, they recommend it for people who inject drugs, who either share injection tools or engage in high-risk sexual behavior.

So in short, it's mostly people who are practicing high risk sexual activity and are at greater risk for... It's estimated that there are over a million patients living in the US right now who are HIV positive and more than 700,000 patients have died in the US since AIDS was first reported. What's concerning to me is that new HIV infections are occurring in about 81% of males versus only 19% of females. So, Dan's a perfect candidate for us to encourage to use PrEP.

Jill Terrien:

That's great Frank. That really kinda just gives us a lot of great guidelines. And as you say, an A recommendation in a draft statement is pretty remarkable. So tell us, how do you use PrEP?

Dr. Domino:

Alright, so PrEP, it goes by the brand name Truvada and it contains two medications that we currently use for post-exposure prophylaxis, Tenofovir and Emtricitabine. These drugs are given as one pill, and they're taken once a day, they're very safe to use. Their major issue is that the dose may need to be altered based upon creatinine clearance. So, if someone's on a medication that might alter creatinine function, alter kidney function, we should watch renal status while they're on it, especially if they have other drugs that are... That engage in it, that can alter renal function.

Jill Terrien:

So Frank, I have a question. So it sounds like you have to do some lab work and you have to do some background investigation on your patient's medical history. What kind of treating issues and concerns are there? So I'm thinking about, is this something he's gonna have to take for life or is this a recommended period of time that he takes it?

Dr. Domino:

Sure well, first question is we're great. I think if you have a patient who's interested in this, the first thing you should do is bring them in, do an HIV test, you wanna check creatinine, talk about their high-risk behavior and ways, other ways, to decrease their exposure risk. And then you start the medication, it's once a day. You should bring them in at three months and then six months and then a year and just see them regularly to just see how they're doing with their medication and re-check their laboratory functions, in particular HIV, STI screening and kidney function.

So you wanna have risk reduction a primary focus of those visits. Now concerning, do they have to take it the rest of their life? I think that's really a function of how the patient chooses to live. If they get in a long-term stable relationship with someone who's HIV negative and they remain HIV-negative, I think you can then talk to them about coming off it unless they're gonna have sex outside that relationship. And that's high-risk behavior. With Dan, our patient here, he's already had chlamydia, he's already had one serious exposure risk. And we need to remind folks that even though we can treat STIs, having one really puts you at great risk for all sorts of things that we need to be aggressive about counseling them.

Jill Terrien:

So how effective is it?

Dr. Domino:

Well, this is the remarkable thing. Based upon really large, national, and international data with regular often missed doses, it's over 70% effective. And when someone is very good and takes it every day and still engages in very high-risk behavior, it lowers their risk by over 90%. So this is a remarkable preventative tool that if used in conjunction with counseling and testing can have a dramatic impact, we know that there are over a million persons in the US who are HIV positive, we also know that the vast majority of them who are getting new cases are men who have sex with men. So fortunately for women, they're being more careful, men are being less careful and we need to protect and prevent this disease.

Jill Terrien:

So this leads me to my next question. So now you're gonna prescribe this for Dan potentially. And are you encouraging him, enabling him to be promiscuous?

Dr. Domino:

So this discussion can happen with giving the hepatitis B vaccine or the HPV vaccine to our teens. There is no data at all, that shows you change patient's behavior for the worse by offering them preventative treatments, whether it's the HPV vaccine or in this case, Truvada for the pre-exposure prophylaxis. There is no data. These are people who are often in this case, engaging in high risk behavior and if anything, all your interaction with them, all your testing and all your counseling is apt to make them less high risk. So, I would counter any argument that thinks, "Alright, you're just encouraging bad behavior." That they're missing the point. And what this medication does, is open the door to a great deal more prevention than we're currently providing.

Jill Terrien:

And possibly Dan has to come in and see you on a regular basis. So again, those interactions and a chance to have further discussion and more about preventative care is right there.

Dr. Domino:

I think, pre-exposure prophylaxis, that goes by the acronym PrEP, is going to be something that's gonna be a regular part of our primary care practice. People may be apprehensive about using it, but it's a very, very safe drug and it has life saving and life-extending abilities.

Jill Terrien:

Thank you, Frank.

Dr. Domino:

Oh Jill thanks so much for discussing this with me.

Practice pointer: Invite your patients who are having high-risk sexual exposures to take pre-exposure prophylaxis for the prevention of HIV transmission.