Stepping Up to Offer PrEP: Firm Foundations in HIV Screening, Prevention, and Treatment

Hello, my name is Matthew Hamill. I'm an associate professor in the Division of Infectious Diseases at Johns Hopkins School of Medicine, Baltimore, Maryland. And in this session, Stepping up to Offer PrEP: Firm Foundations in HIV Screening, Prevention, and Treatment, we will spend some time thinking about how we actually offer PrEP to patients when they come to see us.

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Faculty

This slide shows my disclosures.

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Learning Objectives

The learning objectives for this session is to identify candidates and offer appropriate regimens for PrEP.

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Case 1

So, let's start with a case. A 60-year-old man reports to his primary care office for his annual wellness check.

Generally speaking, he's in good health. He's taking a beta-blocker for hypertension, but he does mention that he is a bit worried about the quality of his erections. And this is something that he's noticed over the last six months or so, but hasn't felt the need to speak with his provider, but now wants to take the opportunity to discuss it in more detail.

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Question 1: What would you do next?

So what would you do in this context?

The most appropriate response here is B, to take a medical and sexual history so that you have a more comprehensive picture of this patient and their general health and sexual health and well-being. There are many things that can lead to sexual dysfunction, including medication side effects, including psychological and psychiatric conditions, and also including anxiety around sexual function.

So, it is important to take a detailed medical history to make sure that you're thinking about all of the potential organic causes of sexual dysfunction, and also to take a sexual history so that you can place this individual within their context in terms of their sexual life.

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Tips on Taking a Sexual History

There are many different ways of taking a sexual history, and it's important that we as providers develop our own styles so that we feel comfortable with the way that we ask questions and the order in which we ask them. But here are some tips about how to make it easy for your patients and for yourself.

So, promoting a comfortable and nonjudgmental environment is really important. Some of these nonverbal cues that we present in our places of work can be really important for patients. It's important that we don't make any assumptions about gender, gender identity, what pronouns somebody uses, their sexual orientation, or the type of sex in which they're engaged.

As a general piece of advice, I would say avoid asking unnecessary information. We need to be specific so that we can guide our patients correctly. But it's also important that patients don't feel that you're peppering them with lots and lots of questions about their sexual behavior.

One thing that really helps is if you explain to a patient, as I do, I'll say, "I'm going to ask you lots of different questions. Every question has a point to it, and the point of the questions is so that I can assist you with decision-making." Without that context, then patients don't understand, necessarily, why you're asking the questions that you ask.

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The 6 Ps of Sexual Health History Taking

There are many different ways of taking a sexual history. This structure of the "six Ps" can be very helpful, not only for providers who are new at taking sexual history, but also as a good reminder to those of us who've been taking sexual histories for many years.

So think about "Partners," that's the first P. Then you ask, could you tell me about your current relationship, or relationships? And then about "Practices." So, time-limited, in the past three months, or in the past six months, what type of sex have you had? Or you can also ask what parts of your body do you use during sex? And that will help you to understand which anatomical sites have been exposed so that you can offer appropriate testing.

You want to know about "Past STIs." Here, in particular, knowing whether someone's had a history of syphilis is really important. It allows you to interpret their serology, if that serology were to come back as positive.

And then to ask about "Protection." What do you do to protect yourself from STIs, including HIV? The next P is around "Pregnancy." Do you have any desire to have children or to have more children?

And then there's another P, which kind of cheats. It puts three Ps within it. So, thinking about how we talk about sex in a way that focuses on pleasure rather than on disease and pathology. So we can ask a patient a question like, "How's your sex life going? What concerns do you have? If you're not sexually active, would you like to have a sexual relationship, or a better or different sex life?"

Thinking about problems: Any problems that a patient is having with their sexual life or their sexual functioning. And then finally, the last P is for pride. What support, if any, do you have from your family and friends about your gender identity or sexual orientation?

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Case 1, continued

So let's go back to our case, case number one.

So during further discussion, the patient explains that he's been divorced now for several months, after having been married for a very long time, and he's ready to start dating again. Condoms are something that he's not familiar with. He was married for many years, and he never had to think about condom use. His ex-wife took care of the contraceptive needs. And right now, he wants to be sexually active, but is not necessarily planning on having a long-term monogamous relationship.

So he's concerned about two things. He's concerned about his sexual performance, namely his ability to maintain an erection, and he's also worried about STIs. He's heard on the news, he's heard on the radio, that STIs are increasing at alarming rates in the United States. So he has this background worry about his sexual performance and also concern about acquiring sexually transmitted infections.

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Question: Should you discuss pre-exposure prophylaxis (PrEP) with this individual?

So in this context, should you discuss pre-exposure prophylaxis?

AV, no slide, just show faculty speaking

It'll come as no surprise that the answer that I would pick is A, yes. This patient has disclosed to you that he intends to become sexually active. He's not planning on going straight into a long-term monogamous relationship. He has some worries about condom use, and he's also concerned about sexually transmitted infections. So in many ways, this is a perfect scenario to discuss pre-exposure prophylaxis.

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What is Pre-Exposure Prophylaxis (PrEP)?

So what is pre-exposure prophylaxis, or PrEP? I'll use the term PrEP, and, specifically, talking about HIV pre-exposure prophylaxis. So PrEP is the use of antiretroviral medications by people who are currently uninfected with HIV to protect them from acquiring HIV, either from sex or injection drug use.

And that, taken consistently, that PrEP has incredible efficacy and effectiveness. That PrEP reduces the risk of acquiring HIV from sexual exposure in the region of 99%, and from injection drug use by approximately 75%. So, here, I'm talking about the reduction in HIV risk using oral PrEP medication taken daily as prescribed.

PrEP is recommended for adults and adolescents weighing 35 kilos or more who are at risk of acquiring HIV infection. And I mentioned the reduction in risk by taking oral PrEP. There have recently been exciting studies that have shown a 100% protection from HIV acquisition amongst cisgender African women using a long-term injectable method of PrEP, which we'll talk about shortly.

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PrEP Guidance: CDC

So the CDC guidelines around PrEP are very helpful. What they recommend is that all sexually active adults and adolescents should be informed about PrEP for prevention of HIV acquisition. It should be part of a comprehensive HIV prevention package that includes discussions of PrEP, discussions of PEP, how to take PrEP as prescribed, how to use condoms properly and consistently, that screening for other sexually transmitted infections is important, and also preventing STIs with vaccination.

So there are sexually transmitted infections such as HPV, and hepatitis B, and MPOX that can be prevented by the administration of vaccination.

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Who Can (and Should) Provide PrEP? You!

So who should and who can provide HIV PrEP? And the short answer is that we all can.

All of us are really well-equipped to provide HIV pre-exposure prophylaxis. And by all of us, I mean those of us who work within healthcare, be they primary care providers, HIV specialists, people who work in STI clinics or in substance use disorder treatment programs. All provider types can assist and/or provide PrEP for our patients. And depending on where you live and where you work, then nurses and pharmacists may be at the front line of provision of HIV PrEP.

And also, we have partnerships in the communities. So community-based organizations in the field also have a great role to play when we're thinking about how we increase knowledge about PrEP, and how we help our patients to access this medication.

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PrEP is Appropriate for Primary Care

Some providers think, "Well, this is specialist work. This is something that needs to be done by infectious disease doctors or HIV specialists or people who are working in STI clinics." But really, that isn't true. You don't need to be an infectious disease or HIV specialist to prescribe PrEP. Any licensed provider can prescribe PrEP.

Actually, the provision of PrEP is really very straightforward in the vast majority of cases. And PrEP can really easily be integrated into primary care. And we should use the skills that we have when we're dealing with other preventable conditions. I think we can apply these skills to providing our patients with HIV pre-exposure prophylaxis. So, nearly all of us are really comfortable with prescribing metformin for diabetes, prescribing statins for cardiovascular disease, hyperlipidemia. Both of these medications can have serious side effects. And we have to be thoughtful about the patients that we use them in.

The same goes for PrEP. But once you start providing PrEP, you will realize that this is not a difficult medical intervention. It's something that is straightforward. It can be woven into our day-to-day practice.

And the other point to make is around equity, that making PrEP part of primary care can really improve access and help address some of the disparities that we see in PrEP use and access to PrEP here in the U.S. That primary care providers working in the most affected communities can also make the greatest difference.

So, my call to arms is that we can all do this, that most of the time it is very straightforward, that it allows us to build relationships with patients. It allows us to talk about sexual health and well-being in a way that we might not be able to if we hadn't gone into those discussions thinking about offering HIV PrEP to our patients.

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Current PrEP Options

Currently, there are four different PrEP options. There are two oral and two long-acting injectable medications. So, as you'll see on this slide here, on the left-hand side, there is a combined pill of emtricitabine plus tenofovir disoproxil fumarate, or TDF. And this option is available as a generic medication. And we also have a second once-daily oral medication, and that's a combination, again, of emtricitabine, but this time with tenofovir alafenamide, or TAF.

Looking to the right side of the screen, there are now two different long-acting injectable medications.

The first is long-acting cabotegravir, which we've had access to for some time now in the U.S., and this is a 600 mg intramuscular dose that's given once, and then four weeks later as a loading dose, and then after that, it's given every eight weeks. There's a seven-day window around the dose of cabotegravir, so it allows a little bit of flexibility for a patient to have either an early or a slightly late dose to accommodate travel or work, for example.

And then lastly, on the bottom right, we have lenacapavir, and this is a very exciting medication that's recently been approved for the prevention of HIV. And this is given as an injection every six months. This is given subcutaneously. The first injection is given, followed by two days of oral lenacapavir, and then after that, there's a six-monthly subcutaneous injection, as I mentioned. And again, there is some leeway around dosing in that it's acceptable to give the lenacapavir dose either up to 14 days early, or 14 days after the scheduled dose.

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Mechanisms to Improve Conversations About PrEP

As a primary care provider myself, I understand how busy primary care visits can be. There are so many competing demands. Time is short. If somebody's presenting with headache, for example, then you may think, how am I going to incorporate PrEP into my primary care conversations? So there are some tips that we can use that will help us in this respect.

I think one of them is, one of the most important is to normalize PrEP as a prevention option for any person who is or plans to be sexually active. We as healthcare providers are really good at prevention. We talk about vaccines. We talk about healthy living as a way of preventing future cardiovascular disease or metabolic disease. And again, we can use those skills, those communication skills in particular, to introduce HIV PrEP into our conversations.

Sometimes patients don't know how to or don't feel comfortable in initiating the conversation. So, it's really helpful if we can initiate conversations with our patients. And not everything has to be done on the first visit. Sometimes we have to build rapport and trust with our patients so that they understand that we are providing patient-centered care, that we're engaged fully in shared decision-making, that we're not being judgmental based on their sexual behavior or injecting practices.

It's important, too, that we avoid the use of stigmatizing language and that we set up spaces within our clinics that feel safe and welcoming. So, for example, we would promote representation of different minority groups, for example. And if possible or appropriate, then to display signals of acceptance, such as people who may wear a Pride pin on their clothing or on their lanyard.

And then finally, to try to integrate sexual health and harm reduction in your practice so that talking about PrEP gets folded into your everyday so that when you're talking about smoking cessation, reducing harm from alcohol, vaccination, promoting a general health and well-being, that sexual health and well-being becomes a norm in those conversations.

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PrEP Services are Billable

PrEP services are billable, and in this table here, you will see a variety of different PrEP-related codes. These are divided into codes that can be used at an initial visit and those that can be used at second and subsequent visits.

So this table will be a helpful aide-memoire, so as to remind us that we can bill for PrEP, and these are some of the different codes that we can use.

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Case 2

Let's move now to case two. This is a 23-year-old woman who reports to her family medicine physician for a checkup, and she also is due to have her next dose of injectable contraception.

She's living at home with her parents in an underserved and rural area. She's worried that her partner may be having sex with other people. She's not sure, but that's a concern that she has.

She's heard about PrEP, and she wants to take it, but she doesn't want her partner or her parents to know, and she can't afford to purchase PrEP.

So your clinic has daily oral PrEP available, but it has not yet provided injectable PrEP.

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Question 3: What would you do?

So, what do you do in this scenario where you have somebody who's concerned about their risk for HIV and other STIs who is keen on PrEP, but is worried about disclosure to her family and her sexual partner?

The most correct answer here is B, to offer a bridge with oral PrEP now so that she can protect herself from HIV infection with the aim of switching to long-acting injectable PrEP once her insurance approval goes through.

Likewise, referring her to a sexual health clinic that's 40 miles away is putting barriers in the way. It's preventing her from easily accessing PrEP. So again, the position of ordering PrEP and providing oral PrEP now, and then in the fullness of time, transitioning to long-acting injectable PrEP provides this patient the most protection from HIV.

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PrEP Deserts: Geographical Barrier to PrEP

Just like food deserts, there are healthcare deserts, and there are PrEP deserts, and what I mean by that is that there are geographical and transport barriers to accessing PrEP.

The way that we define a PrEP desert is living in an area where you have to travel longer distances of between 30 minutes and 2.5 hours to access PrEP, and only one in nine rural counties have organizations that provide PrEP, and living in a PrEP desert really does dramatically decrease the likelihood of PrEP use.

So, living in a PrEP desert really does decrease the likelihood of being able to access PrEP compared to people who live in areas that are not PrEP deserts. So, for example, men who are eligible for PrEP who live in a PrEP desert were 65% less likely than their suburban-dwelling peers to access this preventative medication.

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PrEP Coverage

PrEP is a Grade A USPTF recommendation, which means that private insurance and Medicaid are required to cover PrEP medication.

Private insurance and Medicaid are required to cover PrEP because it's a Grade A USPTF recommendation. For patients who are underinsured, there are also patient assistance programs, which can help patients to access free or very low-cost PrEP medication.

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Key Points

So to summarize, making PrEP part of diverse areas of healthcare can improve access and help to address disparities.

The current PrEP options include both oral and injectable medication. One of the real advantages of long-acting injectable PrEP is that it can be timed to be given at the same time as, say, for example, long-acting contraceptives.

PrEP should be normalized as a preventative option for anyone who is or plans to be sexually active.

PrEP should be available to anybody who asks for it as well as people who we may traditionally consider to be at enhanced risk for HIV acquisition.

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