An Amazing Way to Prevent HIV infection in High Risk People

We embrace health and wellbeing in EVERYONE. Some people are at higher risk of being infected with HIV. For some people it is a distant memory back to the 1980’s when HIV cut through healthy people like a plague. It is indiscriminate. Science has shown us a way to prevent people from becoming infected with HIV, and it is abbreviated as “PrEP” (pre-exposure prophylaxis) (i.e. taking medication before something happens in order to make it not happen in the first place). I offer screening, counseling, and prescriptions for PrEP when appropriate. If you or someone you know fall into the category of high risk people, please contact our office for a Meet and Greet appointment and we can discuss what we can do at Serenity Osteopathic clinic.

Here is a rather technical summary from an excellent medical database called Up To Date (it looks at all the medical literature that is out there and rewrites their informative topics any time something is new).

SUMMARY AND RECOMMENDATIONS

●Up to two million new HIV infections still occur annually worldwide. Pre-exposure prophylaxis (PrEP) with antiretroviral medications is an evidence-based strategy that can be used to prevent new infections among those at risk. (See ‘Introduction’ above.)
●PrEP using tenofovir disoproxil fumarate-emtricitabine (TDF-FTC) can reduce the risk of HIV transmission by greater than 90 percent in patients who are at high risk for acquiring HIV, depending upon the level of adherence. (See ‘Overview of HIV pre-exposure prophylaxis’ above and ‘Efficacy of oral pre-exposure prophylaxis’ above.)
●To determine if a patient is at high risk of acquiring HIV, clinicians should assess sexual risk and drug-using behaviors over the last six months. (See ‘Assessing risk of HIV acquisition’ above.)
●To assess the potential risks of treatment with TDF-FTC, patients should be evaluated for evidence of HIV infection, renal disease, osteoporosis, hepatitis B virus (HBV) infection, and pregnancy (table 3) (see ‘Assessing the risk of treatment’ above):
•All patients should have HIV testing (eg, a fourth generation antigen-antibody test) to be certain they do not have undetected HIV infection. If a patient has had symptoms of acute HIV infection, and/or a recent high-risk exposure in the last four weeks, additional testing for HIV RNA should be performed. (See ‘HIV testing’ above.)
•For patients with evidence of reduced kidney function (estimated glomerular filtration rate <60 mL/min/1.73 m2), pre-exposure prophylaxis should not be prescribed. (See ‘Renal function’ above.)
•Tenofovir disoproxil fumarate is considered a first-line treatment for chronic HBV. Thus, TDF-FTC can be used as part of a PrEP regimen, and can also be used to treat chronic HBV. However, if a patient does not continue other antiviral therapies for HBV, discontinuing PrEP may result in a flare of their HBV. (See ‘Hepatitis B virus infection’ above.)
•Information should be obtained regarding a history of or risk factors for osteoporosis. We obtain a baseline DXA scan in patients who have a history of osteoporosis if recent testing is not available, as well as those at high risk for osteoporosis. (See ‘Osteoporosis’ above.)
•For pregnant women, the risk of acquiring HIV must be weighed against the risk of using antiretroviral medications during pregnancy. In general, tenofovir disoproxil fumarate and emtricitabine (both category B) are felt to be safe for use in pregnancy. (See ‘Pregnancy’ above.)
●PrEP is generally not needed for patients who engage in low-risk behaviors (eg, consistent condom use, exclusive oral sex). However, for the following HIV-uninfected patients who are at high risk for HIV transmission, we recommend PrEP with daily oral TDF-FTC (Grade 1A). Patients should have normal kidney function and be committed to medication adherence and close follow-up (see ‘Candidates for pre-exposure prophylaxis’ above):
•Men and women who have a sexual partner who is HIV-infected and has a detectable viral load
•Men who have sex with men who are at high risk for sexual transmission of HIV
•Transgender women who are at high risk for sexual transmission of HIV
•Heterosexual men who infrequently use condoms and have sex with female partners who are from areas of high general HIV prevalence (eg, sub-Saharan Africa)
●We also suggest PrEP for other high-risk populations (Grade 2B). These include (see ‘Candidates for pre-exposure prophylaxis’ above):
•Heterosexual women who infrequently use condoms and have sex with partners who are at high risk of HIV infection
•Heterosexual men who infrequently use condoms and have sex with female partners who are from low prevalence areas but are at high risk for HIV
•Injection drug users who recently (ie, the last six months) report sharing needles/equipment even if they have initiated substance use treatment
●TDF-FTC for PrEP should be administered once daily for as long as the risk of infection persists. Alternative dosing approaches may be an option for certain patients who can reliably predict when they will have condomless sex. (See ‘Preferred regimen’ above and ‘Duration of pre-exposure prophylaxis’ above and ‘Alternatives to daily oral therapy’ above.)
●PrEP should be provided in conjunction with counseling on other risk reduction methods (eg, consistent condom use, safe needle practices) for maximal protection. (See ‘Patient counseling’ above.)
●Routine monitoring for adherence and safety is important for patients who use PrEP. This includes regular HIV antigen/antibody testing, comprehensive screening for sexually transmitted infections, and monitoring of renal function (table 3). (See ‘Patient monitoring’ above.)
●We discontinue TDF-FTC in patients whose estimated glomerular filtration rate falls below 60 mL/min/1.73 m2 (calculator 1 and calculator 2), and in those with persistently declining renal function, even if clearance remains above 60 mL/min/1.73 m2. (See ‘Patients who develop renal insufficiency’ above.)