Special Considerations in HIV Management - Episode 23

Initiating and Managing Patients on PrEP

William Short, MD, MPH, AAHIVS: So for PrEP, or pre-exposure prophylaxis, I think what we’re really looking at is anyone that considers himself to be at risk for HIV acquisition. You know the CDC [Centers for Disease Control and Prevention] has come forth with a set of guidelines that sort of lump people into categories. So high-risk heterosexual sex, high-risk men who have sex with men, and then intravenous drug use.

But what I think that is more important with is, what does the patient perceive their risk to be? And I think the message has to get out that there is a drug out there that can prevent HIV acquisition. Most of the times I’m asked, “What’s the latest status on the HIV vaccine?” And my comment back is, “It’s still in development. But why focus on the vaccine when we have a drug that can prevent HIV acquisition?” And I think that’s a message that’s just not getting out there like we would like it to get out there. So I think any person at risk, or if they feel they’re at risk, really should, or would be a great candidate for pre-exposure prophylaxis with Truvada.

So the safety and efficacy of Truvada or the components, which are emtricitabine and tenofovir disoproxil fumarate, I think when you look through all of the trials of pre-exposure prophylaxis, we see like we see in the HIV treatment paradigm. People have a little bit of nausea when they start, but that nausea tends to go away.

When you look at long term, again, when you look at Truvada, … we see the toxicity is really long term. But we know that most patients are not on Truvada for the long-term when they’re using it for pre-exposure prophylaxis.

Right now what we see is that we can’t use the newer version of tenofovir, which is tenofovir alafenamide. We’re still lacking data on that. There are 2 large clinical trials going on, and we’re waiting for those results to be published before we can feel comfortable using the newer form.

I think when most people think of Truvada they think of kidney toxicity and bone toxicity. We do know that in the long term that can occur. But, again, as I said, most people on PrEP are on it for a short term, most around 6 months or less. And we do know that once you stop the Truvada, the bone loss does reverse.

So I think providers have to really get the message out to patients saying there is something. One of the things I’ve realized through the years is that most providers are unaware that there is a drug to prevent HIV acquisition. So I think it’s very simple. They need to know that it exists. They need to know it’s safe, it’s efficacious, and then be willing to talk to patients about it. And I think if they’re not willing to talk and they’re uncomfortable, then they need to refer. And I think that’s the thing; the answer is to not talk about it. Because if you get someone who goes out and acquires HIV, then they’re living with the virus for the rest of their life and are forced to use antiretrovirals.

Whereas if you have a drug on a short term, maybe someone’s not in a relationship and is dating or is not ready to settle down yet, it gives them a chance to protect themself from acquiring HIV. So I think providers really need to give just basic messages. And if they’re uncomfortable, refer the patient.

I think the biggest challenge with PrEP is for the patients who don’t have a lot of sexual activity. So the recommended dose right now is daily dosing of Truvada. The problem is not everyone comes in, and people come in and say, “You know, I have sex maybe once a month. Do I really have to take a drug every single day when I may only have 1 sexual encounter?” And there are data on what we call “on-demand PrEP,” which would be to give 2 doses right before the sexual activity, one 24 hours later, and then one 48 hours afterwards. And there are some efficacy data out there that this does work as well. But right now the recommendation is still to use daily dosing. And there will be, in the future, injectables as pre-exposure prophylaxis. But currently right now, we’re limited with just Truvada daily.