This transcript was automatically generated from the video recording and may contain inaccuracies, including errors or typographical mistakes.

Among People Accessing Mental Health Care

So, given the ‑ given the peculiar circumstances of my practice, which is in an HIV clinic, I become sensitive to the fact that HIV is a bad illness and you probably want to avoid it if you can. And I think Dr. Fishman has had the same experience. And so, what we wanted to talk to you today about is a role for mental health professionals in providing something called PrEP, pre‑exposure prophylaxis, a preventative for patients with risk factors for getting infected with HIV.

So, there are still 20,000 people getting infected a year in the United States, and we think this is a bad thing. So, we really want to try to help prevent HIV infection. And our patients often are vulnerable.

Impact of Mental Health Conditions on HIV Risk and Outcomes

So, research has shown that people with mental health conditions are more likely to get HIV infected. And we're more ‑ and are more likely to experience what we call premature mortality. That is, given the average person's survival with HIV, our patients are less likely to survive to that length. They die earlier.

And then people with mental health conditions are less likely to receive and persist on antiretroviral therapy. They're less likely to get an undetectable viral load, and they're less likely to remain in HIV care or in any kind of care.

The HIV field, there's a ‑ there's a concept called churn, in which people come into care and go out of care and come into care and go out of care, and disorganized, chronically mentally ill people, that contributes a great deal to that ‑ to churn.

Mental Health Professionals’ Responsibility to Recommend PrEP

Dr. Fishman: That's right. And this is a feature we see in our patients who have psychiatric conditions, addiction conditions, or both. Retention in care for all sorts of conditions are attenuated. And so, it's an we need to deal with and need to confront and mitigate risk factors for.

Dr. Treisman: So, the obvious ideal target for us is a person with high risk for HIV infection who's not yet infected and who could get infected. And this is a relatively recent circumstance that we can give people a pill they can take every day, and they can be absolutely safe from getting infected.

So, who's at biggest risk and what's our responsibility? So, we know people with mental health conditions are at increased risk, particularly Dr. Fishman's patients. Our patients see us more often than they see other kinds of medical professionals. So, even in the HIV clinic, one of our great strengths has been that we see the patients frequently. So, we are able to get patients on HIV treatment and get them undetectable more effectively than other clinicians because we're seeing them all the time. And talking to them turns out to have a ‑ have a lot of impact on whether or not they take our medications. So, we're effective at doing that.

Then mental health professionals discuss sexual health issues with patients. And we're very good at talking about difficult things since we often have to talk about them.

And then other specialists are not as knowledgeable about managing the mental health conditions that we manage and therefore are less likely to be able to manage the ‑ the complexities of our patients.

Dr. Fishman: I think that's such an important issue that, as mental health specialists, we see it as our role to be able to have these conversations that might be initially seen as awkward conversations that other healthcare providers might shy away from. But either we've had the experience or been trained, or if we haven't, we should practice and learn to be able to do it. But it's just so important to be able to talk comfortably with patients about all sorts of risk behaviors, sexual health, drug use, injection drug use, in a way that gets them to be forthcoming. So, we can explain risk behavior mitigation, including the idea of initiating PrEP.

Who Should Be Considered for PrEP? CDC Clinical Guidance

Dr. Treisman: So, who should be considered for PrEP? The CDC clinical guidance says all sexually active adults and adolescents should be informed about PrEP and the risk for acquisition of HIV.

And PrEP greatly reduces the risk in people who may be exposed to HIV through drugs or sex. The group of patients that I'm most concerned about are ‑ I've already ‑ most of the people who are daily injecting drug users who I take care of, they're on PrEP. But the people who trade drugs for sex or who are manipulated using sex regularly, they're at risk also. And there are people who often haven't disclosed their risk behaviors and need some ‑ need an opportunity to do that.

Reasons to consider same‑day PrEP. There are barriers to PrEP access in ‑ in the sense of patients getting the opportunity to get the drugs prescribed for them.

We tend to increase retention if we talk to people about PrEP and get them on PrEP. And then we want to match the standard of care for other kinds of therapies. So, getting our patients with schizophrenia to take their antipsychotic drugs is a big deal for us. But we probably also want to get people who ‑ who are at risk for HIV to take their medications. And often one of the big conversations that we have with patients is about adherence to their treatment plan.

Dr. Fishman?

Dr. Fishman: Yeah. And the more that we can integrate our thoughts and concerns and incentives for patients to improve their adherence to medications, their motivation to be retained in care in multiple arenas, you know, the more it all comes together in a kind of integrated one‑stop shop.

That's not always possible. Patients may have multiple different HCP care points and multiple specialists, but the idea, for example, of patients who might be on long‑acting injectable MOUD, like extended‑release buprenorphine, might be, as you mentioned, on long‑acting antipsychotics for bipolar disorder or schizophrenia or other conditions, and might at the same time be candidates for long‑acting injectable PrEP. Right? What a great thing in terms of improving adherence, that we now can have PrEP in a long‑acting injectable format, and being able to say, "You're coming in, you're getting all of these things. We're focusing on your addiction, we're focusing on your mental health, we're focusing on your HIV risk reduction." I think there's a synergy for adherence and retention there by integrating them.

Dr. Treisman: Yeah. And that's what we ‑ that's what we found in our research in the HIV clinic that our patients, actually, once we've started working with them, are more likely to take their HIV medicines as well as their psychiatric medicines, they're more likely to show up for their visits, and they're more likely to get undetectable viral loads.

Available PrEP Options for At‑Risk Adults and Adolescents Weighing ≥35 kg

So, what are the available options? The available options are really two different things. One is two ‑ two of medications in a single pill that you can give ‑ that you can give once a day. There's two drugs in each of these combinations. One is FTC or 3TC; they're ‑ they're interchangeable drugs, but the one pill once a day is the FTC formulation. And then a drug called tenofovir. And tenofovir comes in tenofovir regular and tenofovir alafenamide, and the alaninamide, you can give a much lower dose. So, it's the newer drug. And these two combination drugs are once a day.

There are other patterns that people have ‑ have developed for people who take the drug where they ‑ where they take the drug on a day they're going to have sex, and for the next two days. The problem has been that people who try to do that often don't get on the ‑ don't take the medicine soon enough. And at least for most of us, I think I speak for the bulk of people who do PrEP work, that the best thing is if they'll just take one every day. It's a very low side effect, very, very well‑tolerated approach.

The newer and more exciting combination for us is inject ‑ long‑acting injectable drugs. One is cabotegravir, and one is lenacapavir. These two drugs can be injected, and they last for months. So, people ‑ so people who are getting long‑acting injectable treatment for substance use disorders can get these injections as well.

And they've been very effective in places where they've been trialed. And people actually seem to be, unlike the patients' response to injectable anti ‑ antipsychotics, patients seem to be excited about this. I've had numerous patients who are HIV infected who've asked if they can go on injectable HIV medications.

So, the medicines we use for PrEP are really the same medicines we use for HIV treatment. It's just that in HIV treatment, we have to have three oral drugs minimum and two drugs injectable or maybe three depending on which ‑ which drug you're talking about, to prevent the virus from ‑ from reproducing and getting resistant.

Dr. Fishman: And I will say that the same enthusiasm you're describing in patients who are being treated for active HIV infection for the long‑acting injectables, I've also seen in PrEP patients in a prevention mode, where the convenience and the adherence boost is very comfortable for a lot of people.

Dr. Treisman: And the idea that ‑ the idea that you're protected from ‑ from an impulsive moment of sharing a needle or having sex with somebody is really important, especially considering the data on STDs in the United States, which is shockingly high, that is, we have very, very severe epidemics right now of gonorrhea, syphilis, and chlamydia. And ‑

Dr. Fishman: Dr. Treisman and I practice in Maryland, which has the honor, I suppose, of being one of the syphilis capitals of the US. So, it's ‑ it's really remarkable how much of a problem that remains across multiple different STIs.

Choosing Between PrEP Options

When choosing between PrEP options, there really are a couple of things that are practical in terms of what you might choose. The nice thing about the oral option of two drugs is that it's easy. You can write a prescription. The person ‑ the person is on ‑ can give the medicine at the pharmacy, and you don't have to ‑ there isn't a big rigmarole. The injectables, you have to have a person who will inject those injectables, and who ‑ and who can, and you have to get them sometimes authorized, which can be a nuisance, although ‑

Dr. Fishman: That's right. And they're not going to be on everybody's formulary, and there might be co‑pays. That's right.

Dr. Treisman: Although I'm told that that's going to get better. I can't tell you for sure that it will. But the orals are widely available. There's ‑ there's ‑ you don't have to have anybody who knows how to do the injections. The problem is that there's a daily pill burden. They have to take a pill every day, and ‑ but they can ‑ they can ‑ if they're ‑ if they ‑ if they're so inclined, they can take those drugs on demand and say, "Okay, I know I'm going to be doing this today," or "I'm doing that today, and therefore I'm going to take PrEP."

The injectables, you don't have to think about it. You get injected every six months or probably every year fairly soon. And the problems for us is that getting the injections done can be daunting. Although I'm told that pharmacies will now be able to inject PrEP for ‑ for us, so that ‑

Dr. Fishman: That's right. And some of the MinuteClinics and the supermarket chains, for example, in their in‑store pharmacies are now advertising broad injection clinics. So, the possibility of long‑acting antipsychotics, the possibility of long‑acting injectable PrEP in a Safeway supermarket just like you ‑ I think that's going to be an increasing delivery footprint in the country.

Dr. Treisman: Yes, I think that's ‑ I think that's ‑ in fact, in psychiatry, I think that's going to be... If you're ‑ if you have an office practice of psychiatry in private practice, you can't really afford to have a nurse to inject your two patients that you're giving injectable PrEP to. I think it would make it very daunting to do that. You can do it, but again, there's issues about us being able to give injections in our offices, whereas being able to go to the pharmacy and get an injection will be very helpful, I think. So, I think that's going to actually be an important element in ‑ in using PrEP.

But many of us have patients who come in who you wouldn't think are at risk. So, I have a very high‑functioning patient who I see for psychotherapy. And he, after about a year and a half of working with me, disclosed that he visits prostitutes. And I'm discussing PrEP with him, which he's somehow as highly intelligent as this person is, never considered that he might get infected with a sexually transmitted disease visiting prostitutes.

So, those are the kind of cases where you might want to be thinking about giving people PrEP.

Strategies for Integrating PrEP into Mental Health Care

Dr. Fishman: I think that vignette is a nice starting off point for the discussion about having conversations with people about their sexual lives and their sexual risks. I think that that's an extreme case of somebody who didn't reveal a risk behavior for a year, but it does happen. And so, all of us need to sharpen our skills and, you know, not feel embarrassed or daunted by asking these questions, which at first might seem awkward. And if even an expert like you doesn't get it for a year, that information, it does remind us that there's a dimensional variability about people's willingness and forthcomingness. And so, we just have to keep at it and asking the questions.

And as we know, this is a little off topic, but sexual side effects are, for example, one of the leading causes of patient nonadherence for a whole host of our pharmacological therapies. So, I can't emphasize enough. We've got to be able to be straightforward in asking patients about their sexual lives, their sexual health, their sexual choices. And then that leads to questions of sexual risk behaviors for conditions like HIV, as we're discussing today.

So, when you're trying to do this, you want to figure out who you want to do it with. Obviously, there's a world full of people who think that vaccinating everybody you can against a fatal illness is a good idea. And essentially, this is the ultimate vaccine because vaccines protect you up to a point. These PrEP drugs protect you almost absolutely. That is, even a person who's not taking any HIV medication, who's got a high viral load, you're not likely to be able to be infected by them, no matter what you do if you're taking PrEP. So, you're well protected. It's a really good protection.

So, there's the step of identifying who you want to give the drug to. The CDC and other places say, why not give it to everybody? And they're, you know, everybody who is going to have sex or who might go to a party and use drugs. I'm more narrow than that, but I do think that a lot of our patients have risk factors that we don't know about.

And I've had one college student that Dr. Fishman and I actually saw when we were working together who went to a party and got infected with HIV early in the HIV epidemic back in the early '90s. And it was a single event. I don't know that I would have put her on PrEP if I'd been seeing her before that, but ‑

Dr. Fishman: It does raise the issue of a broad range of vulnerabilities.

Dr. Treisman: Absolutely. When you talk to a patient about PrEP and what their options are, whether they want to think about taking a pill every day, or having a plan with taking pills in a particular order, or whether they want to talk about an injectable in vaccinations once every six months or once a year, and then the question is whether you're going to refer to the person to a primary care doctor or whether you're going to prescribe the drug yourself. And then thinking about how to maintain that and keep the person going on their treatment.

Dr. Fishman: Well, you raise a great point. Let's talk about that because many psychiatrists and other mental healthcare professionals may say, "Gosh, what's ‑ the scope of my practice is actually prescribing the PrEP and monitoring the technical aspects. Is that in my scope?" And I would say, yes, it can be, and maybe yes, it ought to be, but everybody's got to pick their own kind of practice boundary choices.

But at the very least, I think it is clearly our responsibility as psychiatrists and other mental health professionals to be having discussions about PrEP and to kind of identify those with the highest degrees of risk and make the recommendation to them. You mentioned the possibility of a referral to primary care. If it's not something that we're going to do in our own individual practices, coordinating care, integrating care with other medical professionals, PCP and others. There are certainly practice settings where there's an integrated team, and those make it easier, where in one‑stop shop, there might be ID folks and PCP folks and addiction folks and psychiatry folks and nursing folks to be able to administer injections and all the multi‑disciplinary action you might want.

And those are obviously ideal situations. But even in a private practice model of psychiatry, having the conversation. Just that is so powerful. And bringing up the possibility and suggesting that a person might go to their PCP, and maybe having a collegial collaboration with that PCP. It's what we do for blood pressure, even if we're not prescribing the lisinopril itself.

But, you know, listen, for our vulnerable populations, I think about my addiction clinic, where patients have so much comorbidity, and unfortunately, their access to primary care is limited for all the reasons we know. I'm certainly not a hypertension specialist. I tell the patients, listen, I'm a B or B‑minus blood pressure doc. But if you're seeing no other PCP, seeing me as a B‑minus blood pressure doc is better than no blood pressure doc. So, you know, you pick how you're going to manage the individual practices. But I think everybody's got to dip a toe in this water. Would you agree with that?

Dr. Treisman: Yeah. If you think of your patients who are under 40 that you see, let's say your patients, you see individually, what percentage of those people have a primary care doctor?

Dr. Fishman: Exactly. I mean, even never mind that they see one, but that they've contacted their Medicaid MCO to be able to have one identified on their chart. It's a minority or certainly a small majority. And then when you add, do they access them and ask the question, when's the last time they saw them? Certainly, among many patients, the utilization footprint is low, low, low.

I'll give you an example that just happened last week. I have a patient who is ‑ got a methamphetamine addiction, has a vulnerability to indiscriminate and high‑risk sex with other men. I've treated him with PrEP. I collaborate closely with his PCP. I also treat him for bipolar disorder. And his PCP was going to treat him for a Giardial infection. And he appears saying, "I've started to take metronidazole," but the PCP may not have known that he was also a binge drinker and may not have remembered the disulfiram effect of metronidazole. So, I've got to kind of dig deep into my old pharmacology knowledge and call the PCP and say, "Maybe we should pick an alternative to metronidazole so he doesn't have a disulfiram reaction." But it's just an example of how we've really got to stretch a bit, I think in terms of ‑

Dr. Treisman: I think that the "stay in your lane" thing in medicine has been a very bad thing.

Dr. Fishman: Yeah. There you go. That's a nice way of saying it.

Dr. Treisman: It's nice if somebody comes to you with community‑acquired pneumonia and they ‑ they ‑ they don't have IgA deficiency. It's just a circumstance of getting pneumonia once. That's a very nice kind of case. And then is it a primary care doctor or an infectious disease specialist? You treat them once and ‑ one and done, and it's great. The problem is, most people aren't like that. Most people have multiple factors in their life that affect lots of different other factors in their life. So, the drugs have interactions, and the treatments have interactions.

We, I think ‑ we ‑ I don't think we're obligated to give people PrEP, but I do think that it's a good thing to do. It does deepen the relationship. And the question of our scope of our practice, you know, most of us are clinicians. There's no rule that says we can't treat the whole patient. And I think that this is one of these areas where we can make a big difference for people, especially considering that the quality-of-life issues of being infected with HIV are significant.

Dr. Fishman: And at the very least, helping our patients be informed and motivated and be better advocates to get that care from other practitioners if we're not going to do it. Somewhere in that dimension. Absolutely.

Roles for the Whole Mental Health Care Team

So, roles for the whole mental healthcare team. Everyone can normalize

Dr. Treisman: Everybody can normalize PrEP. That is making PrEP part of the conversation, leads to reducing stigma and helping people think about their circumstances. And also it opens up a whole area of conversation that might not have anything to do with PrEP, in which you can educate people about sexually transmitted disease risk and talk to them about fertility issues and talk to them about birth control and all those other kinds of things that come out of a conversation about what kind of sexual behaviors are you involved in, and what do you do and what would enrich your life.

Dr. Treisman: Then the‑ the fact that a team helps, team‑based care improves PrEP uptake and helps people be less stigmatized by the conversation. And if you're comfortable talking about sex, the patient will be more comfortable talking about sex. And so, I think that's a very important element.

Dr. Fishman: Got to ask about sex.

If You Can Prescribe, You Can Help Prevent HIV!

Dr. Treisman: And then, you know, the question is, if you're a prescriber, can you initiate PrEP and monitor PrEP in qualifying patients? I think any healthcare provider with prescriptive authority should be able to identify candidates, discuss the options, and initiate and coordinate  PrEP, even if you're not going to be the primary prescriber. Although I can tell you, I think it's a lot easier to just be the primary prescriber rather than try to ‑ try to do it ‑ try to coordinate and get somebody else to give people PrEP. I can't even get people to do surgery on people who need it urgently.

Dr. Fishman: By the way, I'd even go a little further. I would say any clinician, prescriptive authority or not, you know, one of the things about our field, you mentioned this before about stay in your laneism, is that we really need broader integrated care approaches. And it's one of my important elements in training and mentorship of my non‑medical colleagues; the ‑ the counsellors, the therapists, the care managers, the care coordinators, is that treatment is everybody's business, including medication treatment. And I'm not asking you, the therapist, to prescribe the treatment, but if you have more touchpoints than I do and have a therapeutic alliance, then conversations about medicines, indication for medicines, whether it's MOUD, whether it's antipsychotics, whether it's PrEP about response, about side effects, all of those should be in the scope of either even not prescribing clinicians. Do you agree?

Dr. Treisman: Absolutely. I work with a wonderful social worker who has a private practice for therapy and who has sent me several people who she's concerned about. Because she works in a primary care office, is a separate thing, about PrEP and sexually transmitted diseases to educate them and to consider giving them PrEP. And it's very easy to see those patients and prescribe PrEP for them.

The Value of NCCC’s PrEPline for Psychiatric HCPs

So, there's a psychiatric provider hotline to help people give PrEP. And I'm going to just show you this video clip of the psychiatric hotline. I'll tell you a little bit about it afterwards. Can you go ahead and show this clip?

[Video playing] Thanks for the opportunity to join this important dialogue about the connections between behavioral health and HIV. Hopefully, people are feeling inspired from today's presentation to take the next step in their practice. And when you're ready, we have a warm line you can call to ask questions.

My name is Dr. Carolyn Chu, and I serve as Chief Clinical Officer for the National Clinician Consultation Center, or NCCC. We're a unique part of the Ryan White AETC Program and operate the National PrEPline, an on‑demand, cost‑free consultation resource for healthcare professionals.

We have provided almost 4,000 individually‑tailored consultations to practitioners in different settings across the entire U.S. This includes providers newer to HIV care as well as experienced specialists.

Our team is happy to answer questions about the latest guidance and best practices, medication selection, monitoring, and other topics. Not only do our callers trust us to give them high‑quality, evidence‑based information, but we also help save them time and increase their comfort and confidence with PrEP. It's very easy to reach us. Just call 1‑844‑ASK‑NCCC or visit our website to learn more.

Accessing the NCCC PrEPline

Dr. Treisman: So, this is the NCCC PrEPline, which is a UCSF, San Francisco cooperation, to help people give PrEP. And you can get consultation from these people. This phone number I'm showing you. It's 844‑ASK‑NCCC, and they can give you input on anything that you call them about, including drug interactions. And you can go online to them and ask them questions. They're very helpful if you want to do this. And it gives you good backup. So, I think that this is a very useful thing to know about and will help a lot of people.

Referrals: Partner Pathways If You Do Not Provide PrEP

Then, if you can't prescribe the PrEP yourself or you feel uncomfortable doing that, you can refer to primary care and ‑ and the health department, actually in Maryland, and probably most other states has ‑ it has pathways to get to PrEP that are fairly easy. So, most of the doctors in the health department are very eager to give people PrEP.

One of the things that is an issue for us is reimbursement for the time we spend educating patients about PrEP. And although you can put it into the time that you bill for psychotherapy and psychiatric education, there are many places where your institution that you're at make money from pharmacy prescriptions, and PrEP is a money maker for pharmacies. And so, if you're in a hospital‑based clinic or you're an institutional clinic where the pharmacy utilization is helpful to the bottom line of your institution, you probably can ask them to support your efforts to get people on PrEP as part of ‑ as part of ‑ part of the way they do billing. We're ‑ we're involved in this right now at our place.

Dr. Fishman: And you should advocate to get credit for it because it helps with resources for the work that you're doing.

Dr. Treisman: Exactly. And advocate for yourself to get ‑ to get some kind of support for the work that you're doing, getting people on PrEP because it's good for the bottom line of the place if you have a pharmacy‑linked, and it's good for the patients.

Dr. Fishman: You know, you raise a very good point, though. Unfortunately, in the broken American healthcare system, these financial incentives are so real, and they are sometimes barriers to rational care. And the thing you point out about lack of proper incentivization, if that's a word, lack of proper incentives for us in mental health and psychiatry to do this broad kind of important work. Those barriers are considerable ‑ considerable.

If I think about my organization as a primary addiction‑focused specialty care system, you know, my medical staff are doing so many different things, both in bed‑based care and outpatient care, and they're running as fast as they can to stay in one place, and they're prescribing MOUD and they're prescribing antidepressants and they're doing detox, you know, all the stuff that you know, they're doing. And then I ask them, and I want you to identify the vulnerable patients and initiate them on PrEP. It's a big ask. And trying to find ways of getting additional reimbursement, we don't have some of the additional add‑on codes, for example, that general medicine does, as you point out. Maybe we can add minutes to the fee‑for‑service reimbursement for the session, but it's not the same thing.

So, I do wish that there were a rational way of ‑ and maybe this is in the future ‑ a rational way of incentivizing this kind of work because people follow the incentives.

Dr. Treisman: But even if you're thinking about managed care and cost, PrEP, even ‑ or HIV treatment, even ‑ and it's least expensive is still quite expensive.

Dr. Fishman: Another good point.

Dr. Treisman: So, a big price per year.

Dr. Fishman: Yeah.

Dr. Treisman: And so, if your system is interested in cost containment, one of the ways you can contain costs is by not letting people get infected with HIV. And so, a conversation with the higher‑ups about how to incentivize this is a good one.

Dr. Fishman: That's right. And getting them to think not just about this quarter's or ‑ or this week's costs, but the immense costs of what it means downstream for people to have HIV. That's right. And preventing it.

Take‑home Points

Dr. Treisman: So, take‑home points for us before we start answering your questions are: patients at risk for HIV are seen in mental healthcare settings. And HIV prevention belongs in routine mental healthcare. Whether we are prescribing it directly or indirectly, I think it's part of our responsibility.

Preventing HIV is beneficial for patients in the public health at large and strengthens therapeutic alliances. And then you have to have a ‑ you have to have a role in ‑ in discussing risk for HIV.

And the implementation should be team‑based if possible. And educating people and decreasing stigma and supporting them and coordinating PrEP care through direct prescriptions or partner referral pathways is really good for everybody, including the relationship between you and your patient. There's nothing better than having patients who, over time, build more and more of a therapeutic alliance with you.

I think that ‑ let's see. We have ‑ I know we have questions. So, do you want to curate the questions, or do you want me to just go through this list?

Dr. Goldberg: I think we're going to do our posttest questions, then we'll come to the audience.

What do you remember?

Posttest 1

Dr. Treisman: Okay. So, post‑quest testing number one. I recognize that regardless of my specialty, it's my responsibility to recommend HIV PrEP to patients living with mental health conditions and risk factors.

Posttest 2

Okay. Second question. I have effective strategies to integrate PrEP discussions into routine mental healthcare consultations. And hopefully, we've accomplished that today.

Posttest 3

And number three, I feel prepared to recommend PrEP for people who can benefit from it.

Dr. Treisman: Okay. So, I want to move to some of these questions that people asked. 

Questions and Answers

Dr. Goldberg: So, why don't I jump in and I can funnel some of these to you both? Thank you first and foremost for your presentation. We have a lot of questions. Let's see if we can get through in the time that we have.

So, James asks, is it necessary to be tested for HIV before getting treated with PrEP?

Dr. Treisman: It is ‑ it is essential because the ‑ if you have an infection already, the two‑drug combination or the single injectable isn't enough to treat you adequately. So, everybody should be tested. And we actually had a whole section on the steps of testing, but essentially, an HIV ‑  a regular HIV test with a viral load will tell you if people are infected right away. So, if you get a viral load test and people don't have any HIV virus in their blood and they don't have the antibody, you're good to go. So, it's a single test.

There used to be a recommendation that you test people once and then again in six weeks to make sure that they didn't get infected. And when you first tested the antibody, yet. But if you do a viral load, you don't have to do that because the virus is present on your test.

Dr. Goldberg: Right. And as far as how long you've been HIV‑positive for as a variable when considering PrEP, if you haven't developed full‑on AIDS, does that bear?

Dr. Treisman: Yeah. So, if you have the virus in your blood, you've got the infection, you've got to have treatment. It doesn't matter when you were exposed. So, the question about exposure risk is, it takes about six weeks to develop the antibody, plus or minus. So, if you get infected and you're doing the antibody test, then you have to wait to make sure that the antibody doesn't develop from an exposure that occurred right before you started. But if you ‑

Dr. Fishman: But the simple algorithm is HIV‑negative with risk factors, PrEP HIV plus full‑on HIV HAART treatment.

Dr. Goldberg: Okay. Very helpful. Here's a question from our colleague, James. He asks, in the setting of an adolescent, if you're interested in prescribing PrEP, but there may not be parental knowledge or agreement, how does that ‑ how does that play out?

Dr. Fishman: Well, each state has different rules about the age of consent for various different medical lanes or conditions. So, there might be an age of consent for substance use treatment, an age of consent for psychiatric treatment, and an age of consent for reproductive care. So, I think the key is to think about what the rules are in your local state.

But more importantly, I think, think clinically before you think legally. Better to try to have patients seek the support of loved ones. And if parents can be identified as a possible support, getting to yes, to include them. Now, there are certainly circumstances in which, you know, you think that's dangerous for a young person. The parent is going to be punitive or dangerous. And that's why we have confidentiality protections. But getting to yes, to allow young people to broaden their support, talking to their adult caregivers together, learning how to coach those adult caregivers to be supportive rather than punitive, is always a preferable clinical path if you can get there.

Dr. Treisman: So, in some states, someone is considered to be an emancipated minor if they're sexually active versus whether they're ‑ if they're pregnant. And you can find that out. If your notes say that you think in your ‑ in your chart, say, "I think this person is at risk, and the only safe thing to do is to prescribe PrEP for them to prevent HIV." Depending on the state, I think you're going to be fine. In Maryland, I would certainly be very happy if I had a sexually active adolescent who's using drugs to give them PrEP. I wouldn't hesitate.

Dr. Fishman: That's right.

Dr. Treisman: If I could get their parents involved, as Dr. Fishman said, I would. But we do have a lot of people who come to us whose parents really can't be involved for a variety of reasons. And it's important to advocate for your patient.

Dr. Goldberg: Yeah. All makes sense. So, our colleague, Eshima, asked a very fundamental question about psychiatric medicines that we should be thinking about in terms of drug‑drug interactions with PrEP. Can you speak to that issue a bit more about drug‑drug interactions with psychotropics?

Dr. Treisman: Yeah. So, the big ‑ the big drug‑drug interactions you're going to come up with are ‑ are anticonvulsants. The antidepressants are mostly going to be fine. There are ‑ there are occasional things that are warnings, but there aren't ‑ but there aren't very many for ‑ for PrEP, even injected cabotegravir. Oral PrEP, almost ‑ almost ‑ there's almost nothing you have to worry about, except the anticonvulsants occasionally. But with antidepressants and anti ‑ and neuroleptics very little issues with PrEP.

The one exception to that, there's a very rare renal toxicity with tenofovir that doesn't occur with tenofovir alafenamide, or probably doesn't. And so, people on lithium doses that are significant, you might want to think about increasing your monitoring when you start PrEP for the first couple months of their renal function. But I think that that would be a debatable point.

Dr. Fishman: And Dr. Treisman, you mentioned anticonvulsants. Would you recommend that people recheck a valproic acid level, or that's too conservative?

Dr. Treisman: No. So, the anticonvulsant you're worried about is between cabotegravir and lenacapavir and the anticonvulsant, and it's because of the effect of the anticonvulsant on the lenacapavir. And so, people would worry maybe that people wouldn't be as well protected with cabotegravir if they were on an anticonvulsant. And that's a ‑

Dr. Fishman: I see.

Dr. Treisman: That's a ‑ if you ‑ if you do the drug‑drug interaction computer thing, it'll come up as a ‑ as an indication ‑ as a relative contraindication. And you can look at it. And what we've done is we've ‑ when people are on treatment with an anticonvulsant and are going to get cabotegravir, and it's important to do that. We have a number of patients where that's important, bipolar patients. What we do is we ‑ we monitor their viral load. So, if you're ‑ if you were worried about that, you might get cabotegravir levels, which you can get or lenacapavir levels. Probably, we would just use orals for those patients because those you can get away with.

Dr. Goldberg: A question about timing before taking ‑ medication before having sex to be effective. I guess the question here is ‑

Dr. Fishman: For PrEP on‑demand, what's the right timing?

Dr. Goldberg: Yeah. Yeah, yeah.

Dr. Treisman: Yeah. So, the PrEP on‑demand thing is very interesting because we have some data on it, and there's a method called 2‑1‑1, in which you take two pills the day before, one pill 24 hours later, one pill 48 hours later. And that's pretty effective. And the question is, is that effective for women having high‑risk vaginal sex? And people have debated that. So, it's ‑ it's clearly effective for men who have sex with men to do the 2‑1‑1 thing, but may be less effective for women who are having receptive sex. And so, this is ‑ this is the tenofovir/FTC combination drug or tenofovir/alafenamide/FTC drug.

There's the data, and it's pretty good. The problem is there's a bunch of people who intend to do that and then miss a dose. And if you're doing it, if you're doing 2‑1‑1 as your primary method of HIV prevention, one mistake and you're infected. And it's probably better to encourage people to take daily pills if they're ‑ if they're impulsive. And the people who tend to be impulsive tend to be the same ones who 2‑1‑1 is kind of targeted at. So, I ‑ I tend to push people to take PrEP as a daily thing.

Dr. Goldberg: Makes sense. I have a couple of questions about cost, particularly among uninsured patients, and any resources available to them, and just what ‑ what the cost of PrEP tends to be.

Dr. Treisman: So, PrEP, the tenofovir PrEP, is very inexpensive, and almost ‑ I've never had trouble getting it paid for. I've had trouble getting alafenamide paid for where they want prior approval and blah, blah, blah because of the low cost of the regular tenofovir formulation, but not very expensive.

The injectables are more expensive, and they're fairly costly, and you're going to have to probably get prior approval, which I think is a headache. But I've done it when I've had to do it, and I haven't been turned down yet because it's ‑ I think that politically, the idea that you're going to not give somebody something that would prevent HIV infection to save money for somebody is politically unpalatable for these places. So, if you ‑ if you ‑ if you fill out the form, they're usually going to ‑ they're usually going to pay for it.

Dr. Goldberg: Very, very helpful. I want to thank you both, Dr. Fishman, Dr. Treisman, for just a wonderful presentation. A lot of informative detail for many of our colleagues who may not necessarily be as familiar with some of these important issues in the patients that they're already seeing. So, I thank you both for just a terrific job, and for everyone. We're now going to take a five‑minute break. We'll be back at ten past the hour. See you. See you then.

Dr. Fishman: Thanks, everyone for your attention. Hope that's helpful.

Dr. Treisman: Thank you all. That's great.