PREP

Question 1

Drugs in Prep

Answer 1

Tenofovir and Emtricitabine

TDF-FTC

Question 2

Offer prep to…

Answer 2

• Hiv neg MSM with condomless anal sex in past 6/12 and ongoing condomless sex
• hiv neg MSM condomless sex with HIV pos partner not suppressed on ART
• combination of risk factors

Question 3

When can you consider Tenofovir alone prep?

Answer 3

Heterosexual men and women where FTC is contraindicated

Question 4

Prep and breastfeeding/ pregnancy

Answer 4

All ok
V little found in breast milk
No congenital anomaly from TDF during pregnancy

Question 5

Three specific drugs used in chemsex

Answer 5

1) methamphetamine (Crystal/meth/Tina)
2) mephedrone (meph, miaow miaow, m-cat)
3) GHB/GBL (G, Gina)

Question 6

PWID and prep

Answer 6

Low hiv prevalence in PWID
Don’t give prep where needel exchange and opiate substitution is available and accessed
Chemsex - different and high risk of HIV. Give prep

Question 7

Trans prep prescribing recommendations

Answer 7

• Daily prep to hiv neg trans women having condomless anal sex in past 6/12 and ongoing
• prep for trans women and men with positive hiv partner not on ART
• if trans and only having anal sex - can consider EBD
• discuss unknown efficacy for vaginal sex and prep

Question 8

Considerations for young people and prep

Answer 8

No need for routine BMD scan - evidence is all returns to normal on stopping
Teenagers critical peak of bone mass
Fraser guidance etc

Question 9

Anal sex prep regime

Answer 9

Double dose 2-24 hours before sex
Single dose at 24 and then 48 hours
Continue daily until 48hours post last sex

Question 10

If taking prep for anal sex and interrupted then what’s the advice

Answer 10

If less than 7 days since last dose- single dose to restart

If more than 7 days since last dose - double dose to restart. Consider need for pep

Question 11

Vaginas sex and prep regime

Answer 11

Takes 7 days until working (still take double dose incase can’t wait 7/7) and then continue for 7/7 post last sexual risk

Question 12

Prep regime for PWID

Answer 12

7 days to work, 7 days after last risk to stop

Question 13

Population risk factors for HIV acquisition

Answer 13

Heterosexual black African men and women
Recent migrant to UK
Transwoman 
PWID
Sex work/ transactional sex

Question 14

Clinical indicators for increasing HIV risk

Answer 14

Rectal bacterial STI in past year
Baceterial STI or HCV in past year
Pepse in previous year (repeated courses particularly)

Question 15

Sexual behaviours and risks for HIV acquisition

Answer 15

Condomless sex with unknown HIV status of partner (particularly if anal or multiple partners)
Condomless sex from high risk country
High risk behaviour - chemsex/ group sex
Reports anticipated high risk sex

Question 16

Drug use risk factors for HIV

Answer 16

Sharing kit
Unsafe setting for injecting
No needle exchange or opiate sub programme

Question 17

Sexual health autonomy risk factors for HIV

Answer 17

No option for condoms
Coercive violent relationship
Homelessness or precarious housing
Sex exploration risk or trafficking
Drug/alcohol/ mental health impact

Question 18

WHO definition of hiv substantial risk of acquiring?

Answer 18

Incidence greater than 3 per 100 person years

Question 19

Predictors of HIV infection associations

Answer 19

Concurrent rectal STI
2 or more condomless acts in past 90 days
Prev pep in past 90 days
Chemsex

Question 20

What to cover in discussion re prep and educating patient

Answer 20

Hiv transmission
Testing and window periods
Side effects of prep
Efficacy and adherence
Regime
Pep for risks
Sti testing and prevention
Resources I want prep now
Referral for any support services e.g drugs

Question 21

How to transition from pep to prep and testing times

Answer 21

Test after pep finishes (4 weeks)

Then test again 4 weeks after starting prep

Question 22

Hiv testing required to start prep

Answer 22

Must have baseline 4th generation or negative result in past 4 weeks
Can do a poct and wait results (higher false positives and false neg in early infection)

Question 23

What to send if starting prep and high risk exposure in past 4 weeks

Answer 23

Hiv viral load

Start prep if no Sx, negative poct and ongoing risk and then retest in 4/52

Question 24

Symptoms of acute HIV infection

Answer 24

Commonly rash and fever

Also headache, malaise, arthralgia, sore throat

Question 25

Risk factors for renal disease to consider

Answer 25

Nephrotoxic meds >40 years old Diabetic/HTN

Question 26

Egfr when ok to start prep

Answer 26

>60 | If less than - renal consultant

Question 27

Considerations if patient on prep and also chronic Hep B

Answer 27

Don’t suddenly stop as risk of rebound viraemia and hepatic flare - slowly with LFTs Don’t give event based dosing Vaccinate

Question 28

Daily dosing - minimum no of tablets per week

Answer 28

4 at least ( do alternative days)

Question 29

When to give pep after prep not used correctly? | Anal and vaginal

Answer 29

If less than 3 tablets taken in last 7 days or if last dose was more than 7 days ago If 3 tablets taken in past 7/7 - just have single dose now and covered If vaginal sex - give pep if less than 6 tablets in past 7/7 or more than 48hours since last dose

Question 30

Follow up schedule for prep

Answer 30

1/12 - phone or text to check adherence/ ses 3/12 - hiv, sts, stis, Hep c Annual egfr, creatinine if no renal concerns

Question 31

Side effects of prep

Answer 31

``` Nausea Flatulence Abdo pain Dizziness Headache Most disappear in 1/12 Renal and bone longer term ```

Question 32

What to discuss at prep first visit and to do

Answer 32

``` Prep Medical Hx Drug hx Risk assessment and prep eligibility Acute hiv infection (Sx in past 4/52?) Pepse Any HIV pos partners? Testing hx last 1 year Sex hx ans when last sex EBD vs daily Adherence Renal/ bone Results Follow up schedule Short term side effects ```

Question 33

Baseline prep tests

Answer 33

``` Hiv 4th gen plus POCT for same day Sti screen Hep b and c screen for those at risk Serum creatinine, egfr and urinalysis Pt if needed Hep a vaccination ```

Question 34

Quarterly visit prep

Answer 34

``` ? Need to continue Adherence Risk reduction advise Improve adherence Rec drugs alcohol support Results Hiv/ Hep c sti screen Px for 90 days F/u 3/12 Annual bloods ```

Question 35

If seroconversion on prep

Answer 35

Baseline resistance testing ASAP - check for mutations to prep Consider drug levels Public health questionnaire

Question 36

If renal concerns then minimum testing frequency for hep c when on prep?

Answer 36

6monthly No need for routine urinalysis at follow up if renal function ok and no additional risk factors as low PPV for proteinuria and raised creatinine

Question 37

Bone risk and prep

Answer 37

Reduction in BMD of 1.5-2% at hip and spine after 48 weeks prep No routine bone monitoring If have osteoporosis consider vit d and ca Use frax tool to indicate need for dexa

Question 38

When to stop prep

Answer 38

Change in risk behaviour Renal function <60 egfr Poor adherence and no improvement with support ( risk of resistance) Hiv pos Always check for active hep b before stopping