HIV Prevention

Question 1

What can be said about individuals on ART with an undetectable viral load and transmission?

Answer 1

individuals with HIV who are on ART and maintain an undetectable VL cannot sexually transmit the virus to others, and are less likely to transmit via vertical transmission or with contaminated drug paraphernalia or hygiene items

Question 2

What is PrEP?

Answer 2

an HIV prevention strategy to reduce the risk of acquiring HIV
taken by HIV negative individuals considered at risk of infection

Question 3

Which agents are used for PrEP?

Answer 3

Truvada (TDF + emtricitabine) 1 tab daily
or
Descovy (TAF + emtricitabine)

Question 4

How effective is PrEP?

Answer 4

reduces the risk of acquiring sexually transmitted HIV by more than 90% if taken as prescribed and by at least 74% among PWID

Question 5

What is the key with PrEP?

Answer 5

adherence

Question 6

Who is at risk of acquiring HIV and may benefit from PrEP?

Answer 6

MSM and transgender women engaging in condomless sex within the last 6 months who have any of the following:
-syphilis or rectal STI, recurrent use of PEP, ongoing relationship with HIV+ partner with risk of transmissible HIV, high incidence risk score
heterosexual exposure
-serodiscordant couples engaging in condomless sex where HIV+ partner has significant risk of transmitting to partner
PWID exposure
-sharing drug paraphernalia with a person with non-negligible risk of HIV infection

Question 7

When is PrEP not recommended?

Answer 7

stable, closed relationship with negligible risk of transmission of HIV

Question 8

Which PrEP regimen is generally not covered?

Answer 8

Descovy

Question 9

When might Descovy be used for PrEP?

Answer 9

those with renal impairment

Question 10

What is the “on demand” Truvada regimen for PrEP?

Answer 10

2 pills 2-24 hrs prior to first sexual exposure followed by 1 pill daily until 48 hrs after last sexual activity
-trials only support use in MSM

Question 11

What are the baseline investigations done for PrEP?

Answer 11

HIV status
HBV A/B/C status
baseline STIs
pregnancy
CBC, renal panel, urinalysis
comorbidities: renal dysfunction, mental health, SUD
vaccination status

Question 12

What is a contraindication to PrEP?

Answer 12

HIV +

Question 13

Which patients is Truvada approved for as PrEP?

Answer 13

MSM, TGW, and heterosexuals for OD regimen
off-label: PWID for OD regimen
off-label: MSM for on-demand regimen

Question 14

True or false: Truvada is safe in pregnancy and lactation

Answer 14

true

Question 15

What are contraindications for Truvada?

Answer 15

HIV+
eGFR < 60 ml/min

Question 16

What are some medications on the horizon for PrEP?

Answer 16

long-acting cabotegravir for injection
dapivirine silicone vaginal ring

Question 17

What is the efficacy of the cabotegravir injection for PrEP?

Answer 17

promising trial evidence - superior to oral Truvada
-sexual risk: MSM, TGW, cisgender men & women

Question 18

True or false: cabotegravir injection is approved in Canada for PrEP

Answer 18

false
likely to be approved this year

Question 19

What are the limitations to using cabotegravir injection for PrEP?

Answer 19

access to injection
$$$
insufficient data to recommend in pregnancy currently
unknown reduction in PWID
risk of resistance if pt d/c then exposed to HIV

Question 20

What is the efficacy of the dapivirine silicone vaginal ring for PrEP?

Answer 20

promising trial evidence - 50% reduction vs placebo

Question 21

During which phases of pregnancy are pregnant women at an increased risk of acquiring HIV?

Answer 21

conception phase
pregnancy
early postpartum
incidence of HIV during pregnancy 2-6x greater than non-pregnant counterparts

Question 22

How much is the risk of vertical transmission increased in women HIV+ during pregnancy?

Answer 22

9-15x

Question 23

Which regimen is approved for PrEP in pregnancy and lactation?

Answer 23

Truvada once daily

Question 24

What is critical with PrEP use in pregnancy?

Answer 24

adherence
-6 to 7 doses/week for optimal [ ] in vaginal and cervical tissues, especially in 2nd and 3rd trimester due to increased Vd

Question 25

When should PrEP not be used in pregnancy?

Answer 25

same as non-pregnant population -unknown HIV status, HIV+, CrCl < 60

Question 26

Who can prescribe PrEP?

Answer 26

any physician, NP, or pharmacist with a collaborative prescribing agreement can prescribe PrEP

Question 27

Describe proper client PrEP education.

Answer 27

benefits, benefits, benefits! -if taken daily, can reduce HIV acquisition by over 90% via sexual exposure and > 74% of PWID adherence is vital for effectiveness and needs to be stressed at baseline and review at subsequent visits -OD PrEP studies have shown in MSM --> 4 tabs/wk was enough to provide protection against transmission it utilizing PrEP on demand --> provide instructions 7 days is required to meet effective [ ] (in anal and vaginal tissues) when taken OD (controversy if takes 7-20 days in cervicovaginal tissue) PrEP does not prevent other STBBIs/STIs side effect expectation and management --> improve adherence

Question 28

Describe proper PrEP follow up.

Answer 28

at 1 month, then every 3 months: -review recent blood work -assess for ongoing indication -ongoing exposure -HIV status negative -if receiving on-demand --> indication to change to OD? -discuss adherence -assess tolerability

Question 29

Describe proper discontinuation of PrEP.

Answer 29

in MSM or TGW: -d/c 2-28 days after last exposure heterosexuals or PWID: -d/c 28 days after last exposure on demand: -take last tablet 48 hours after last exposure *recommend to rpt HIV serology 8-12 weeks after d/c*

Question 30

What is PEP?

Answer 30

post-exposure prophylaxis -involves the use of HIV medications in an HIV negative person who may have been exposed to HIV to prevent transmission

Question 31

What is key with PEP?

Answer 31

should start as soon as possible -must be started within 72 hours of exposure

Question 32

Where should a person present in order to access PEP?

Answer 32

any emergency department -emerg physician will assess risk of exposure and need for PEP

Question 33

What is included in the adult PEP kit in SK?

Answer 33

5 day supply of: -Truvada one tablet once daily AND -dolutegravir 50 mg one tablet once daily intent is to give pt a chance to get drug coverage in place and take the prescription to be filled

Question 34

True or false: there are pre-assembled peds PEP kits in SK

Answer 34

false assembled on an as needed basis

Question 35

What is the duration of treatment for PEP?

Answer 35

28 days in total

Question 36

Describe proper PEP follow up.

Answer 36

all clients should receive baseline HIV test client should receive HIV test at: -4-6 weeks post-exposure -3 months post-exposure -6 months post-exposure assess client for switch to PrEP following completion of PEP, should they have ongoing risk factors