Welcome to Short Scoops in HIV

In this asynchronous online activity, we will be exploring timely clinical topics related to caring for people living with HIV.


HIV Prevention: Navigating Real World Challenges

Ron is a 19-year-old male who visited a minute clinic three days ago with an acute onset of fever, fatigue, myalgia and headache.  His past medical history is consistent with an episode of primary syphilis and rectal gonorrhea in the past year; both were successfully treated.  He is sexually active with both male and female partners and does not consistently use barrier precautions.  He was on PrEP more than a year ago, but did not routinely follow up for his appointments and his provider stopped renewing his prescription.

His rapid HIV antibody test and influenza test were negative at the minute clinic.  He was then referred to your clinic and expresses a motivation to reinitiate PrEP?

Questions:

  1. Would you initiate PrEP for the patient at this time?  Why or why not?
  2. What other things would you do or consider at this visit?

28 thoughts on “HIV Prevention

  1. Cori Blum says:

    I’d like to know when his last possible HIV exposure was, and whether the rapid test is 3rd or 4th generation, to explore possibility of acute HIV given symptoms. Would send HIV PCR along with reflex to genotype if positive, and PrEP start labs, and if cannot rule out acute HIV would start same day with a rapid HIV treatment regimen (likely dolutegravir + Tenofovir/FTC while awaiting viral load results. If VL negative, could switch to a PrEP regimen once those results return.

    • William Short says:

      Cori are you using 4th generation rapid tests? We are not doing rapids and have everything done through ag/ab testing at our hospital with a quick turn around time (less than 24 hours).

  2. John Beltrami says:

    I would not. Given the symptoms reported, the patient may have acute HIV. I would order a rapid antigen test (e.g., Determine) to get a better indication of possible acute HIV and send off blood for an HIV viral load. I would explain to the patient why PrEP is not appropriate at this time and counsel him on acute HIV and to abstain from sex or use protection (e.g., condoms) if going to be sexually active, because if has acute HIV, then likely to have a high viral load making transmission to others more likely.

  3. John Beltrami says:

    Thanks Dr. Short. I’ve worked in non-clinical HIV/STD public health for a very long time, but just recently started seeing PrEP patients. What I’m hearing from some patients/providers is that some patients have no interest in using condoms once on PrEP and the focus of condom promotion tends to be on STI prevention. I support the concept of meeting patients where they are, but your graph is a reminder that someone on PrEP could still acquire HIV (e.g., receptive anal intercourse without condoms from someone with an extremely high VL), so it seems to me that a client not wanting to use condoms on PrEP should still be prescribed PrEP, but counseled that their chance of getting HIV is further reduced with condoms. Please let me know if you think there is a better or different approach to consider. Thank you, John

  4. William Short says:

    Great points, I usually discuss the efficacy of PReP but I remind patients that PReP does not protect against STIs. I also share some local data about the STI epidemic we are seeing in my area (Philadelphia) as well as nationally. I also discuss that there can be serious consequences of Syphilis including neurologic deficits.

    In addition, over time I add in discussion about HPV and its association with cancer, long term HSV, etc. I do not do this all at once because I do not want to make patients think I am trying to scare them into using condoms.

    • Jason Schafer says:

      I really like this approach and think that it has been an effective message for most of our PrEP patients too. The discussion of HPV and its association with cancer, in particular, is one that definitely renewed importance given the expansion of candidates for immunization. We have seen our share of PrEP patients over the age of 26, and we are now more routinely discussing the potential benefits of the HPV vaccine up to 45: https://www.cdc.gov/vaccines/acip/recs/grade/HPV-adults-etr.html.

  5. John Beltrami says:

    I heard that a clinic in Washington, DC checks Tenofovir drug levels, which I think is great, but wonder how costly and sustainable that model is for others to emulate. Of six PrEP clinics that I’ve actually visited (3 in Atlanta and 3 in New Jersey), all ask client about their adherence. My understanding is that data show that for the most part self report correlates with measured drug levels, particularly when a patient says that they are not adherent. I’ve read that the best focused questions are asking a patient how many pills they’ve missed in the last week and last month.

    • William Short says:

      We have had some crazy discordant results between self report and urine drug levels. I like our assay because it is urine based and not very hard to do-the problem is that it has to be sent off and picked up by Fed-EX.

  6. John Beltrami says:

    My understanding is that the # of STIs related to condomless sex is not clearly known yet. It seems some data show increases and some do not. And the reasons don’t simply relate to the idea of less condoms therefore more STIs, because with all of the extra screening, some STIs are being detected that would not have otherwise been so. And I briefly spoke with a research modeler who said that STIs should initially increase, but the fact that these STIs are treated early means that STIs should decrease over time.

  7. Eileen Donaghy says:

    This is a great conversation so far and it looks like everyone is on the same page regarding the initial question of whether or not to initiate PrEP in Ron the sexually active 19 yo.
    I definitely see, in my practice (Phila), the increase in STIs. I’m performing the “triple” screen- pharyngeal, rectal and urethral GC/CT swabs. Commonly I’m finding +CT with the rectal swab.
    It’s really important to discuss what types of sex our patients are having in order to determine their risk.
    Anyone have tips on having that “sex” talk?

    • Idalina Afopa says:

      I warn my patients about using prep on demand and the risk of viral resistance that it entails. I emphasized the importance of adherence once on prep to improve the chances of HIV prevention.

      • William Short says:

        I think it is also important to note that while on-demand approach is being used and is approved in Europe, our indication is still for daily dosing (hope that will change soon). In addition, this is not an appropriate strategy for cis-gender women.

    • William Short says:

      My approach is to tell patients that it is approved for daily use and explain the on demand strategy and I explain the dosing so if they decide to do this approach-they actually use the right on-demand strategy that was studied.

  8. Idalina Afopa says:

    Due to his symptoms I too would start a HIV tx regimen and switch to prep if HIV test turns out to be neg.
    Here in the Bronx, NY we have seen an increase in STI due to prep. I have recently treated my prep pts for syphilis, GC/CT although gonorrhea seems to be more common. In our ID clinic we use a template that always include an assessment of sex practice hx, educates pt on STI prevention (prep does not prevent any other STI). Therefore we always recommend to use condoms concomitantly.
    I would say the average use of barrier is about 50%.

    • William Short says:

      That sounds very similar to Philadelphia. I am seeing a large increase in STIs in both those with HIV and those who do not have HIV. I am never judgmental in my approach but I do warn about the increase in STIs being seen and the risk associated with each of them.

      Most are unaware that syphilis can have long term consequences and it is not just s rash.

  9. William Short says:

    I just completed a monograph with an ED physician and a Nurse practitioner about PReP use in the ED. We have seen an increase in PReP use overall but not in the individuals who need it the most–what are your thoughts on using the ED to screen for PReP given they may see individuals who might not or do not have access to routine medical care.

Leave a Reply