Prepping the internist for prep

Abstract

LEARNING OBJECTIVE #1: To understand the importance of the primary care provider to identify candidates and prescribe HIV Pre-Exposure Prophylaxis (PrEP). LEARNING OBJECTIVE #2: To recognize candidates at high risk for HIV infection and to know how to prescribe and manage patients on PrEP. CASE: A 28 year old MSM patient with a history of gonorrhea and syphilis presented to our outpatient clinic requesting STD testing. The patient reported multiple male sex partners in the past 6 months and had engaged in oral and insertive/receptive anal sex with inconsistent condom use. His medical history was limited to an episode of gonorrhea (2014) and early syphilis (2015) which were both treated. Social history included occasional episodes of binge drinking and rare marijuana use. No history of intravenous drug use (IVDU). He worked as a professional singer in a traveling choir. His vital signs and physical exam were within normal limits. STD testing, including HIV were negative and his RPR titer remained at baseline. The patient returned to the our clinic 3 months later again requested STD testing. His sexual behavior was unchanged. He tested negative for all STDs including HIV and his RPR was stable. 5 months later, the patient returned with a sore throat and for repeat STD screening. His HIV antibody test returned positive. DISCUSSION: This case demonstrates a missed opportunity to have prescribed HIV PrEP. It also shows the need for the internist to recognize their role as first-line PrEP prescribers and to be learn to identify at-risk patients, how to prescribe PrEP, and how to manage the long-term care of these patients. Internists as first line prescribers: The incidence of new HIV infections have remained stable over the past 2 decades with an estimated 50,000 new cases per year. Despite this, the incidence of HIV infection has actually increased among particular groups, including men who have sex with men (MSM) and certain minorities. In 2010, the Centers for Disease Control and Prevention (CDC) reported that nearly 2 out of every 3 cases of newly diagnosed HIV occurred in MSM patients, with Black and Hispanic men disproportionately affected the most. One method to reduce new HIV infection is pre-exposure prophylaxis (PrEP). Multiple randomized control studies including the Pre-exposure Prophylaxis Initiative (iPrEx) and the Intervention Preventive de l'Exposition aux Risques avec et pour les Gays (IPERGAY) have demonstrated that daily or on-demand Tenofovir and Emtricitabine (Truvada) reduce the rate of HIV seroconversion by 44-86 %. Despite the clear evidence, a recent study on provider knowledge and utilization of PrEP demonstrated that though a majority of providers were aware of PrEP, only a minority had prescribed PrEP in the past. This study showed that for non-HIV providers, 77 % were aware of PrEP as a tool for HIV prevention, 38 % were comfortable determining candidacy for PrEP, and only 9 % had previously prescribed PrEP. Identifying candidates: The CDC provides 3 groups of patients to consider: MSM, heterosexual adults, and intravenous drug users (IVDU). MSM: HIV negative men not in a monogamous relationship with male sex partner(s) in the past 6 months who have either: participated in unprotected anal sex (receptive or insertive), had any sexually transmitted disease in the past 6 months, or is in a sexual relationship with an HIV-positive male partner. Heterosexual men or women: Any HIV negative adult not in a monogamous relationship who is sexually active in the past 6 months who either: engages in unprotected sex with partner(s) of unknown HIV status who are known to be at substantial risk of HIV infection (i.e. IVDU or bisexual men) or in a sexual relationship with an HIV-positive partner. IVDU: Any HIV negative adult that has either shared injection drugs or equipment or enrolled in a drug abuse treatment program (i.e. methadone, buprenorphine, or suboxone) in the past 6 months. Prescribing and management: Prior to initiating PrEP, it is necessary to ascertain medication compliance and to perform specific laboratory testing, including HIV, hepatitis B, renal function, and pregnancy testing. If compliance is satisfactory and laboratory values show a negative HIV, hepatitis B, and pregnancy test with a creatinine clearance of >60 ml/ min, then you may proceed to prescribe PrEP. Specifically, Tenofovir 300 mg-Emtricitabine 200 mg (Truvada 1 tablet) daily should be prescribed at a maximum of 3 month intervals. The CDC recommends close routine follow up at least every 3 months. At each follow up visit, assessment of medication side effects should be elicited in addition to repeat HIV, renal function, and pregnancy testing. STD testing should be conducted at least every 6 months. Conclusions: 1) Primary care providers must learn and be comfortable with HIV pre- exposure prophylaxis. 2) PrEP should be offered to high risk groups, especially MSM, serodiscordant couples, and IVDU. 3) Medication compliance and specific laboratory testing must be checked before initiating PrEP. Once started, patients should follow up at least every 3 months.