Pre-Prescription Assessment

Specific pre-prescription laboratory testing should be performed prior to prescribing PrEP with either TAF/FTC or TDF/FTC (Table 3).29,30 Treatment of HIV infection requires a minimum of 2 different drug classes; therefore administering only TAF/FTC or TDF/FTC to a person with confirmed HIV infection can lead to drug resistance. This is one of the main reasons why it is important for clinicians to confirm a person’s HIV status prior to placing them on PrEP.23 An individual found to have HIV infection at baseline should be offered 1 of the recommended combination HIV antiretroviral therapy options based on the current CDC HIV treatment guidelines.23

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The components of TAF/FTC and TDF/FTC have activity against hepatitis B virus (HBV). When persons with chronic HBV infection are prescribed TDF/FTC or TAF/FTC, these agents will also have an effect on the HBV. Therefore, it is important to check the HBV status of any person with HIV prior to initiating therapy and monitor their liver function as there is risk for a flare of HBV infection following discontinuation of PrEP.23

Patients who are prescribed PrEP should be followed up at a minimum of every 3 months to monitor their HIV status. At each follow-up visit, clinicians should assess for any adherence issues, screen for STIs as appropriate, and periodically assess the need for ongoing PrEP. Renal function should also be assessed at least every 6 months in these patients.23

On-Demand or Event-Driven PrEP

For MSM who may not be at continuous risk for HIV but who still want to benefit from PrEP, the use of on-demand dosing (also known as “event-driven” or “2-1-1” dosing) may be considered.31 With on-demand dosing, individuals take 2 tablets of TDF/FTC between 2 and 24 hours prior to a sexual encounter and then continue taking an additional dose every 24 hours until there has been 2 consecutive days without sex. This regimen has been studied in several trials and is recommended by the World Health Organization, as well as the New York City and San Francisco Departments of Health.31-33 On-demand dosing is not recommended for individuals with chronic HBV infection.

Non-Occupational Post-Exposure Prophylaxis (nPEP)

For individuals not on PrEP but who experience an exposure that puts them at risk for HIV infection, nPEP may be considered. nPEP should be started as soon as possible after exposure but not later than 72 hours after exposure.30 Baseline laboratory testing should be obtained and is similar to baseline testing for PrEP (Table 3). However, clinicians should not defer or delay starting nPEP if laboratory testing or results are not available prior to the first dose.30

Current guidelines for nPEP recommend a combination of TDF 300 mg/FTC 200 mg plus an integrase strand transfer inhibitor, either raltegravir 400 mg twice daily or dolutegravir 50 mg once daily (Table 4).30 The nPEP regimen should be taken for 28 days following an exposure. Clinicians should assess if individuals currently on nPEP would benefit from PrEP. If so, at the conclusion of the 28-day regimen, clinicians can transition individuals to PrEP with once-daily TDF/FTC or TAF/FTC.30

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Follow-up antibody/antigen testing should be performed 4 to 6 weeks after initial exposure, with additional testing recommended 3 and 6 months post-exposure.30 If the person presents with signs or symptoms consistent with acute HIV infection (eg, fever, malaise, mononucleosis-like symptoms), the clinician should consider assessing HIV RNA viral load.34 All individuals on nPEP should be counseled to use additional protective barriers, such as condoms, until HIV status can be confirmed to avoid the possibility of transmission of HIV to others.30

Substance Use

MSM who use substances, such as crystal methamphetamine, are at increased risk of acquiring HIV.34 Clinicians should screen for substance use and provide appropriate referrals or support for treatment. Interventions such as motivational interviewing and cognitive behavioral therapy have demonstrated some benefit in this setting.35 Persons who report ongoing substance use should be offered PrEP to minimize the risk of HIV infection.23

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Conclusion

MSM remain a population at increased risk of acquiring HIV infection. One of the primary barriers to receiving appropriate HIV prevention services among MSM is a lack of culturally competent providers. Nurse practitioners and physician assistants can play a vital role in the assessment of these individuals, providing counseling about ways to minimize or prevent HIV and offering access to interventions proven to reduce the risk of acquiring HIV. By providing care that is culturally affirmative, clinicians can help address the disparity of HIV infection among MSM and help achieve the national goal of reducing the number of new HIV infections by 90% by 2030.1

Jeffrey Kwong, DNP, MPH, ANP-BC, AAHIVS, FAANP, is a professor in the Division of Advanced Nursing Practice in the School of Medicine at Rutgers, The State University of New Jersey.

References

  1. What is “ending the HIV epidemic: a plan for America? HIV.gov website. https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview. Updated September 3, 2019. Accessed September 28, 2019.
  2. HIV surveillance report. Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/statistics/overview/index.html. Published April 2019. Accessed September 23, 2019.
  3. HIV and gay and bisexual men. Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/group/msm/index.html. Updated October 2019. Accessed October 9, 2019.
  4. National Association of STD Directors, National Network of STD Clinical Prevention Training Centers, and National Network of STD Clinical Prevention Training Centers. MSM sexual health standards of care: addressing the sexual health crisis among gay, bisexual, and other men who have sex with men (MSM). http://www.ncsddc.org/wp-content/uploads/2017/08/MSM-Sexual-Health-Standards-of-Care-2017.pdf. Published 2017. Accessed October 5, 2019.
  5. Coleman TA, Baur GR, Pugh D, et al. Sexual orientation disclosure in primary care settings by gay, bisexual, and other men who have sex with men in a Canadian City. LGBT Health. 2017; 4(1):42-54.
  6. A guide to taking a sexual history. Centers for Disease Control and Prevention website. https://www.cdc.gov/std/treatment/sexualhistory.pdf. Accessed October, 1, 2019.
  7. The Gap Report 2014: gay men and other men who have sex with men. UNAIDS website. https://www.unaids.org/en/resources/documents/2014/Gaymenandothermenwhohavesexwithmen. October 16, 2014. Accessed October 9, 2019.
  8. Wilkin T. Primary care for men who have sex with men. N Engl J Med. 2015;379(9):854-862.
  9. Kelly CF, Kraft CS, De Man TJ, et al. The rectal mucosa and condomless receptive anal intercourse in HIV-negative MSM: implications for HIV transmission and prevention. Mucosal Immunol. 2017;10(4):996-1007.
  10. Khosropour CM, Dombrowski JC, Swanson F, et al. Trends in serosorting and the association with HIV/STI risk over time among men who have sex with men. J Acquir Immune Defic Syndr. 2016;72(2):189-197.
  11. HIV risk behaviors. Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/risk/estimates/riskbehaviors.html. Updated December 4, 2015. Accessed October 6, 2019.
  12. Smith DK, Herbst JH, Zhang X, Rose CE. Condom effectiveness for HIV prevention by consistency of use among men who have sex with men in the United States. J Acquir Immune Defic Syndr 2015;68(3):337-344.
  13. Pathela P, Braunstein SL, Blank S, Shepard C, Schilinger JA. The high risk of an HIV diagnosis following a diagnosis of syphilis: a population-level analysis of New York City men. Clin Infect Dis. 2015;61(2):281-287.
  14. Johnson Jones ML, Chapin-Bardales J, Bizune D, et al. Extragenital chlamydia and gonorrhea among community-venue attending men who have sex with men – five cities, United States, 2017. MMWR Morb Mortal Wkly Rep. 2019;68(14):321-325.
  15. FDA clears first diagnostic tests for extragenital testing for chlamydia and gonorrhea. US Food and Drug Administration website.  https://www.fda.gov/news-events/press-announcements/fda-clears-first-diagnostic-tests-extragenital-testing-chlamydia-and-gonorrhea. May 23, 2019. Accessed October 6, 2019
  16. Aptima® multitest swab specimen collection kit [IVD], San Diego, CA: Hologic Diagnostics, Inc; 2017. https://www.hologic.com/sites/default/files/2018-01/AW-15641-REG_002_01_0.pdf. Accessed October 9, 2019.
  17. de Voux A, Bernstein KT, Kirkcaldy RD, Zlotorzynska M, Sanchez T.  Self-reported extragenital chlamydia and gonorrhea testing in the past 12 months among men who have sex with men in the United States-American Men’s Internet Survey, 2017. Sex Transm Dis. 2019;46(9):563-570.
  18. Syphillis. Centers for Disease Control and Prevention website. https://www.cdc.gov/std/stats18/syphilis.htm. Reviewed October 1, 2019. Accessed October 9, 2019.
  19. 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control and Prevention website. https://www.cdc.gov/std/tg2015/default.htm. Reviewed June 1, 2015. Accessed October 9, 2019.
  20. American Association for the Study of Liver Diseases and the Infectious Disease Society of America. HCV in key populations: men who have sex with men. https://www.hcvguidelines.org/unique-populations/msm. Updated May 24, 2018. Accessed October 6, 2019.
  21. Prevention of human immunodeficiency virus (HIV) infection: preexposure 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 October 9, 2019.
  22. Vail RM; with the Medical Care Criteria Committee. New York State Department of Health AIDS Institute. Candidates for PrEP. https://www.hivguidelines.org/prep-for-prevention/prep/#tab_2. October 2019. Accessed October 30, 2019.
  23. US Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States-2017 update: a clinical practice guideline. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf March 2018. Accessed November 5, 2019.
  24. Effectiveness of prevention strategies to reduce the risk of acquiring HIV. Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/risk/estimates/preventionstrategies.html. Accessed Updated July 18, 2019. October 9, 2019.
  25. FDA approves second drug to prevent HIV infection as part of ongoing efforts to end the HIV epidemic. US Food and Drug Administration website. https://www.fda.gov/news-events/press-announcements/fda-approves-second-drug-prevent-hiv-infection-part-ongoing-efforts-end-hiv-epidemic. Accessed October 3, 2019. October 9, 2019.
  26. Hare CB, Coll, J, Ruane P, et al. The phase 3 discover study: daily F/TAF or F/TDF for HIV preexposure prophylaxis. Paper presented at:  Conference on Retroviruses and Opportunistic Infections; March 2019; Boston, MA.
  27. Descovy® [prescribing information]. Foster City, CA: Gilead Sciences Inc; 2019. https://www.gilead.com/~/media/Files/pdfs/medicines/hiv/descovy/descovy_pi.pdf. Accessed October 10, 2019.
  28. Truvada® [prescribing information]. Foster City, CA: Gilead Sciences Inc; 2016. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/021752s047lbl.pdf. Accessed October 10, 2019.
  29. US Public Health Service. Preexposure prophylaxis for the Prevention of HIV. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf. March 2018. Accessed September 29, 2019.
  30. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV—United States, 2016. CDC Stacks website.  https://stacks.cdc.gov/view/cdc/38856. Updated May 23, 2018. Accessed October 9, 2019
  31. What’s the 2+1+1? Event-driven oral pre-exposure prophylaxis to prevent HIV for men who have sex with men: update to WHO’s recommendation on oral prep. World Health Organization website. https://apps.who.int/iris/bitstream/handle/10665/325955/WHO-CDS-HIV-19.8-eng.pdf?ua=1. July 2019. Accessed October 10, 2019.
  32. Population Health Division. Important HIV prevention and treatment updates for San Francisco providers. San Francisco Department of Public Health website. http://www.gettingtozerosf.org/wp-content/uploads/2018/11/HIVUpdate_02122019_v2.pdf. Accessed October 10, 2019.
  33. New York City Health. “On-demand” dosing for PrEP: Guidance for medical providers. New York City Department of Health and Mental Hygiene website. https://www1.nyc.gov/assets/doh/downloads/pdf/ah/prep-on-demand-dosing-guidance.pdf. February 12, 2019. Accessed October 10, 2019.
  34. Hoenigl M, Chaillon A, Moore DJ, Morris SR, Smith DM, Little SJ. Clear links between starting methamphetamine and increasing sexual risk behavior: A cohort study among men who have sex with men. J Acquir Immune Defic Syndr. 2016;71(5):551-557.
  35. Carrico AW, Zepf R, Meanley S, Batchelder A, Stall R. When the party is over: a systematic review of behavioral interventions for substance-using men who have sex with men. J Acquir Immune Defic Syndr. 2016;73(3):299-306.

From the December 2019 Issue of Clinical Advisor

Topics:

HIV/AIDS Infectious Disease Men's Health