PrEP in Practice: Key Steps. Quick videos
Clinical Foundations for PrEP: Conversations, Coverage, and Continuity of Care
Short videos. Trusted facts.
With Dr. Jonathan Shuter, Dr. Uriel Felsen, Dr. Raffaele M. Bernardo, and Dr. Rasika Karnik
- Taking a Sexual History
- Insurance Coverage for PrEP
- Starting PrEP
- Tips for PrEP Adherence
- Stopping PrEP
- View the entire webinar here
Taking a Sexual History
Transcript:
Dr. Raffaele Bernardo:
These are important conversations we should be having with all of our patients, regardless of age, sex, race gender, because once you standardize it, it becomes easier, I think, more natural when you’re having these conversations, and how you start off having these conversations is largely a personal preference.
I usually will start off by saying something like. The next thing I would like to talk about is your sexual health. I feel like this is a topic that often goes unaddressed, and is just as important as every other part of your health. So if you don’t mind, I’d like to ask you some questions.
And then from there I try to start off with open, ended questions. I try to let the patients lead the conversation themselves, because number one, sometimes it’s more natural that way, and sometimes patients are more comfortable sort of just ad lib. Talking about their sexual history, but if you find that they are stuttering, or they have a hard time giving you the information you need, you can start asking some more pointed questions, and this could be something as simple as can you tell me a little bit about who you’re having sex with? What are the genders of the people that you’re having sex? With? What body parts are you using to have sex? What methods are you using to prevent pregnancy? What methods are you using to prevent HIV infection?
There are lots of these different things online that you can look for to help organize your sexual history-taking to make it easier. But I think the important thing is that you try to create consistency with having these conversations because they’ll eventually happen more naturally. But it’s important to be comprehensive, because the question you don’t ask leads to the answer you don’t get, and it’s a missed opportunity to perhaps talk about some sort of preventative strategy with your patient.
The other thing that I will add as well. The questions you ask are part of it. But I think the environment you create is just as if not more important than the questions you’re asking. Because anyone in this audience can think about perhaps being asked these questions in two very different scenarios, right? A very sort of whitewashed office, very sort of sterile environment versus an environment that perhaps has some signage on the wall sort of promoting sexual health, you know, depending on the population you’re serving. For example, I’m the medical director for a comprehensive LGBTQ-plus practice in New Jersey. So in our office, although we serve all types of individuals, we do have very subtle gestures of support toward the community. So we have, for example, a pride flag in the waiting room. We have nice modern pieces of art that tie-in the LGBTQ-plus colors as well. So these subtle hints of support, I think, are also very important. You want to create an environment that welcomes these conversations. So I think again, the environment you’re creating is just as important, if not more important, than the actual questions that you’re asking your patients.
Insurance Coverage for PrEP
Transcript:
Dr. Uriel R. Felsen:
The really nice thing about PrEP coverage at this point is that it has a grade A recommendation from the US Preventive Services Task Force, the USPSTF. And so, because there’s a grade A recommendation for it, all insurances are required to cover it without any contributions from the patient.
And for those who are uninsured, there are a lot of access programs through the drug companies themselves, and some states also have an assistance programs. So pretty much anyone who is interested in being on Prep should have minimal financial barriers to being able to get it. At this point.
Starting PrEP
Transcript:
Dr. Raffaele Bernardo:
Not all forms of PrEP are approved for all types of sex. So it’s important to get a sense of who your patients are, who they’re having sex with and what body parts they’re using to have sex. That’s also important when you talk about testing for sexually transmitted infections, you want to make sure that you’re offering comprehensive testing. And this includes three site testing, perhaps for gonorrhea and chlamydia, again, depending on body parts that a patient may use to have sex. For example, oral pharyngeal swabs, rectal swabs which can be self-collected by the patient and or vaginal swabs, which could also be self-collected by the patient or urine sample, for example.
And then we offer blood work for things like HIV, for example, to make sure that the patient at baseline is not living with HIV, we do testing for syphilis and various forms of hepatitis. But most importantly, we have to test for the preexistence of hepatitis B. And the reason is because some of these medications do have activity against hepatitis B, particularly Truvada and Descovy. And so it’s very important to determine whether or not somebody may have an occult hepatitis B infection, because if you do start one of these oral forms of PrEP and then stop, you can actually cause a rebound hepatitis b viremia, and potentially could cause fulminant liver failure. So that definitely wants to be excluded.
One of the things that I think also many offices have implemented as well, which is one of the things for example, we do is same day starts for PrEP. So actually having patients, for example, leave with a prescription, or even a sample in hand to get started the same day, we find that that often helps with adherence. So some offices do have the availability of doing point of care testing for HIV. There is a slightly longer window period for many of these point of care tests, but if you exclude an acute HIV infection clinically so, people who come in without any recent flu, like syndromes, for example, fevers, chills, swollen lymph nodes rash, etc, and their point of care for HIV is negative, you can actually even start same day PrEP, particularly the oral forms of PrEP.
Tips for PrEP Adherence
Transcript:
Dr. Jonathan Shuter:
So I think that’s an idea to introduce really early to the patient that these things that pills require one pill every day. Patients have to be reliable and consistent with tha,t and the injectable, they have to show up every two months and get their injection. Otherwise it’s not going to go well. So I think that that’s a good message to start with.
Dr. Raffaele Bernardo:
So when it comes to talking about adherence, trying to really get a sense of what those barriers might be to adhere to these medications, because it might help you steer the conversation toward one medication or another. I’ve had patients who have had concerns about disclosure. They have roommates, or maybe they live with family, and they’re worried about having a pill bottle with the label of these medications lying around the house. We talk about things to do there. But that might be a candidate, for example, for Apretude, coming into the office for an injection every other month rather than storing medications at home, just as an example.
For me, I would say, the majority of the patients, the community that I do serve is a largely a younger population. So a lot of these individuals aren’t on medications for anything else. And now, all of a sudden, you’re entrusting them to take a pill every day. And so one of the big things that comes up during follow-up appointments is adherence, and not because they want to miss their medication. They just forget, because it hasn’t been part of their daily routine to take a pill every day.
So one of the things we talk about are strategies to remember. We talk about setting daily reminder alarms on their cell phones, for example, or I tell them to put their pill bottle next to something that they will reach for every morning, for example, like their toothbrush or their coffee machin,e just to help with adherence. But I think the one most common thing that I will hear from patients in terms of quote unquote issues with PrEP is just remembering to take their pill.
And, conversely, conversely, I do have a handful of patients that have lots of other medical comorbidities, and they have the other problem. They develop what we call the medicine pill fatigue. So now you’re kind of inundating them with another pill they have to take every day, and so it becomes a similar but not so similar conversation. So both ends of the spectrum.
Dr. Jonathan Shuter:
And, needless to say, for for folks who are on their 1st chronic medicine, we shouldn’t assume that they know how to get a refill or know what a refill even is. They should leave the clinic or your office with a phone number to call if they’re having problems, if they lose their pills, if they have questions about it, because if you don’t give them that and they have a problem, they’re not going to know what to do if they aren’t. They haven’t been trained in the medical system already.
Raffaele Bernardo:
One of the other strategies I mentioned to patients is, I will often offer them if I have available, or I’ll tell them to go pick one up online, is a little pill key chain, and I will tell my patients to keep one or two, I like to call them emergency pills, on them, put it on their backpack on their keychain. So, for example, let’s say it’s a night out, they spend the night at a friend’s house, or whatever the case is, they go to work the next day. They forget, but they have one or two extra pills on them to just sort of take in the event that they forget.
Jonathan Shuter:
The more strategies you offer, the more likely they are to adhere. So so, you know, I think a keychain thing, a pill box, an app, good counseling. All of those things are important, and they should be piled one on top of the other.
Stopping PrEP
Transcript:
Dr. Raffaele Bernardo:
So people’s situations change all the time. There may be a change in one’s perceived risk for HIV infection. So people come on and off PrEP all the time. But it’s important that this is done under the guidance of a provider for a few different reasons. One is, you sort of want to remind the individual that if they do stop PrEP, there is going to be, if they do engage in any risks, any sexual activities or intravenous drug use where they could be exposed to HIV, that they no longer have that medication in their body. And so an alternative form of HIV prevention should be used.
The second thing is, you again want to make sure that you’ve at least addressed the hepatitis B thing at some point, because, again, if there is a missed underlying hepatitis B infection, by stopping these medications abruptly, you can cause a viral rebound, hepatitis B viremia, and potentially fulminant liver failure. For those people who are incidentally found to have chronic hepatitis B, they do have to stay on treatment, at least in the beginning, until they are sort of staged and determine whether or not they need ongoing medication. So we’ll typically narrow them from Truvada, which contains tenofovir and emtricitabine to just tenofovir.
Dr. Uriel R. Felsen:
I think there’s one other special consideration, which is the folks that are that are on the injectable, for when they want to come off, because it’s a long-acting injectable, and the idea of stopping it would be to sort of let the drug levels peter out. But of course, during that period when the drug levels are petering out, you have some amount of of the medication in you, but not necessarily enough to offer protection. And so there is a small risk during that period, if somebody was to acquire HIV, that their strain of HIV that they’ve acquired could become resistant to the cabotegravir. So some people in that scenario have opted to start an oral medication, one of the oral PrEP options, while the cabotegravir is sort of petering out from their system.
Dr. Raffaele Bernardo:
And that’s particularly important, because the resistance mutation that occurs sometimes with cabotegravir renders a lot of these single tablet regimens we use to treat HIV ineffective. So not to say that you couldn’t treat somebody now living with HIV. But your options will be somewhat limited. So that’s a great point, thanks, Dr. Felson for bringing that up.
