Effective implementation of HIV prevention strategies begins with appropriate patient-clinician communication. When initiating a conversation with a patient about his or her sexual history, one of the most important things a nurse practitioner (NP) and physician assistant (PA) can do is normalize the conversation. Asking about a patient’s sexual health is just as important as asking about mental health and physical health.  The conversation should be natural, and the clinician should try to avoid appearing uncomfortable with the topic. This should be a “sex-positive” interview:  meaning normalizing sexual health, normalizing sexual activity, and being able to have a conversation that welcomes the dialogue.

When I am framing my conversation with patients, I do so in the following fashion:  “Just as I have asked you a lot of questions about your physical health and mental health, I’m now going to ask you some questions about your sexual and social history.”

For those not comfortable broaching the topic of sexual health and sexual history, I recommend creating or using a standardized questionnaire that can be filled out by the patient before the visit or in the waiting room. Patients have the opportunity to answer a couple of key questions on paper, which can then be summarized by the provider during the initial visit as part of the patient’s examination.

Routine HIV Testing

The Centers for Disease Control and Prevention (CDC) guidelines on HIV testing advise that anyone from 13 to 64 years of age should be tested for HIV annually, with more frequent testing for individuals who have a greater opportunity to acquire HIV.1

Consent for HIV testing varies from state to state.  In states that have opt-out testing, the clinician does not need to obtain a signed inform consent form. I frame the conversation like this: “Based on our conversations today, I am recommending that we do CBC, CMP, cholesterol, and HIV tests.  Let me know if that’s ok.”  If the patient does not object, the testing can proceed.

In states that continue to require written informed consent, I recommend that a different member of the team who can go through the consent process with the patient handle the forms. This can be done during intake to the practice, with a note that says “annual HIV testing is part of our routine practice.”

If full consent is required, it is typically a lengthy process and can sometimes be a barrier to clinicians offering HIV testing.  I would advise all clinicians to know their particular state’s HIV consent law.  Once you know your state law, figuring out how to best work it into your practice setting is extremely important.

A perfect opportunity to provide HIV testing is among patients who present with symptoms of a sexually transmitted infection (STI). In many settings, including acute care and primary care, a patient may be presenting with signs and symptoms of an STI, but an HIV test is not done because it adds time, energy, and effort to the diagnostic process. Clinicians may be opting for an empiric-treatment approach: treating only based on current symptoms alone. This represents a missed opportunity for offering HIV testing.

Prevention Regimens

In 2019, the US Preventive Services Task Force recommended pre-exposure prophylaxis (PrEP) as a grade A recommendation for persons at high risk of acquiring HIV.2  PrEP regimens have been shown to be up to 99% effective at preventing the acquisition of HIV in persons engaging in high-risk sexual activity.3 Although PrEP is also effective for preventing HIV infection in intravenous drug users, the data are not as strong as that seen in individuals with sexual exposure; however, PrEP does reduce the risk of HIV infection among persons who inject drugs by 73.5%.4

The CDC has recommended the use of 2 medications:  Truvada® (emtricitabine/tenofovir disoproxil fumarate) and Descovy® (emtricitabine/tenofovir alafenamide) for HIV PrEP.  Truvada was approved in 2012 for use in both men and women whereas Descovy, approved in 2019, is only indicated for men who have sex with men (MSM) and transgender women.5,6  Importantly, the CDC now recommends that when a patient simply asks for PrEP, even if they are not willing to share their personal sexual or social history, a provider should at least refer the patient to someone who can provide PrEP.

Prior to starting PrEP, clinicians should ensure that a negative fourth-generation HIV test is confirmed. The HIV rapid screening panels tend to be third-generation tests and are not as reliable as the fourth-generation test. Prior to initiating PrEP for their patients, the CDC recommends that clinicians test for hepatitis B virus infection, check basic renal function, and then consider whether or not the patient has any allergies or other contraindications to taking PrEP.  After initiating PrEP, patients should be seen in the office every 90 days. 

Regarding patient education surrounding PrEP, clinicians should be aware that the internet and social media are full of mixed data that can be confusing to patients. For example, in the United States, the US Food and Drug Administration (FDA) has approved oral PrEP for daily use, intermittent “on-demand” PrEP use may be approved in other countries. Patients who find conflicting information online may not continue to take their daily PrEP dose or only take their medication when they have planned or perceived that they would be having sexual activity, which could greatly reduce the effectiveness of the medication.

Because PrEP is a daily regimen, all of the standard treatment adherence techniques used in primary care should be employed; for example, using pill boxes and/or setting daily reminders on the patient’s phone. However, I have noticed that adherence is not the main challenge with PrEP; rather, the regimen poses more of a persistence issue.  We have found that some patients eventually will decide to stop PrEP use either because they are in a more stable relationship with an HIV-negative partner or because they may have gotten into a more stable relationship with an HIV-positive partner who has an undetectable viral load. In those circumstances, patients tend to fall out of a PrEP program, even though they may still be at risk for HIV acquisition. 

When discussing the risks and benefits of PrEP, clinicians should note that both formulations are HIV nucleoside reverse transcriptase inhibitors. Truvada has been used in HIV treatment and management since the early 2000s and will likely be off patent soon, making it potentially less expensive. The newer medication, Descovy, contains the prodrug, tenofovir alafenamide, that reaches intracellular drug concentrations more quickly than Truvada.  As a result of greater intracellular concentrations, Descovy has been shown to have less effect on renal function and bone mineral density (BMD) compared with Truvada.

With regard to BMD concerns related to PrEP therapy, there are guidelines for the primary care management of patients living with HIV that clearly give us indications on when to do BMD testing for patients receiving antiretroviral therapy. The correlate for HIV-negative patients on long-term PrEP use, however, does not exist.  Instead, BMD screening in patients using PrEP should follow the guideline for screening the typical primary care population, with a few minor caveats.  I don’t recommend that patients taking PrEP receive any additional BMD screening unless they have additional risk factors.

If clinicians or patients are concerned about the potential for acquired drug resistance while taking PrEP, additional steps can be taken. It is known that people who did acquire drug resistance in the clinical trials (a specific M184V genetic mutation) were patients who were undiagnosed with HIV at baseline.7 When they started PrEP, they already had an underlying HIV infection.  This can happen if their antibody test was negative but they had recently been infected. In that circumstance, it is extremely important to obtain a sexual history and to understand whether the patient was screened with a third- or fourth-generation HIV test.

If you are still concerned, the option of doing an HIV viral load does exist.  That will help to lower the window period of detection from 10 to 14 days to 5 to 7 days after infection.  Additionally, if clinicians are concerned about infection and are within 72 hours of a potentially high-risk exposure, post-exposure prophylaxis can still be employed; in this setting, a patient is treated for 28 days with a full antiviral regimen and then transitioned to PrEP as appropriate.  

Related Articles

Continuing Counseling

When we think about HIV prevention in 2020, we now have the tools we need to prevent HIV.  In my home state of Maryland, for example, we saw the lowest number of new cases reported in 2019 since the start of the epidemic.  This shows that HIV prevention strategies are working.  We must, however, make sure that prevention is working for all communities equally. We are finding that more individuals with higher socioeconomic status, greater numbers of white MSM, greater numbers of older MSM, and greater numbers of college-educated MSM are engaging and seeking PrEP. Individuals in those demographics have lower lifetime risk for HIV infection and transmission. We must increase HIV screening and PrEP use in rural communities and communities of color.  

Jason Farley, PhD, MPH, FAAN, is PhD and DNP/PhD Program Director/ Director of the REACH Initiative and co-director of Clinical Core at Hopkins Center for AIDS Research in Baltimore, Maryland.

References

1. HIV testing. Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/guidelines/testing.html. Last reviewed January 21, 2020. Accessed January 28, 2020.

2. Prevention of human immunodeficiency virus (HIV) infection: pre-exposure prophylaxis. US Preventive Services Task Force website. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis?ds=1&s=prep. June 2019. Accessed January 28, 2020.

3. Effectiveness of prevention strategies to reduce the risk of acquiring or transmitting HIV. Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/risk/estimates/preventionstrategies.html. Last reviewed November 12, 2019. Accessed January 28, 2020.

4. Preexposure Prophylaxis for the Prevention of HIV infection in the United States – 2017: update clinical practice guideline. Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf. Published March 18, 2018. Accessed January29, 2020.

5. Truvada® [prescribing information]. Foster City, CA: Gilead Sciences Inc; 2016. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/021752s047lbl.pdf. Revised March 2016. Accessed January 28, 2020.

6. Descovy® [prescribing information]. Foster City, CA: Gilead Sciences Inc; 2019. https://www.gilead.com/-/media/files/pdfs/medicines/hiv/descovy/descovy_pi.pdf. Revised December 2019. Accessed January 28, 2020.

7. Gibas KM, van den Berg P, Powell VE, Krakower DS. Drug resistance during HIV pre-exposure prophylaxis. Drugs. 2019;79(6):609-619.