Already Using PrEP? Some Quick Video Tips
How Soon is PrEP Effective?
Transcript:
Dr. Raffaele Bernardo:
We do have some data that show that for Truvada in particular, it does take about 7 days of continuous use before it achieves levels within rectal tissue that are considered protective against HIV. In vaginal tissue we think this is closer to 3 weeks or 21 days or so. In my practice, I extend that data to include Descovy, although there’s probably a difference between the two. But just for precautionary measures, we typically will also generally recommend the same amount of time, 7 and 21 days, with the rectal and vaginal tissue respectively. For penile tissue, oropharyngeal tissue, or the throat, for example, we don’t have as good data, but largely, I would recommend closer to a 2 or 3 week mark in that regard. But the data that we do have, rectal tissue 7 days, vaginal tissue, approximately 21 days.
For injectable Apretude we believe there is about a 7 to 14 day window before the drug achieves protective levels in the blood after your first injection, so I often will inform my patients, who are already on some form of oral PrEP to continue their oral PrEP for approximately 14 days after their first injection, to ensure that the injectable Apretude has reached levels that are protective against HIV.
Tips for Remembering to Take PrEP
Transcript:
Dr. Uriel R. Felsen
The effectiveness of pre-exposure prophylaxis is directly correlated to how well you take it. Meaning, are you adherent to it? Are you taking it as it’s prescribed every day? And so a lot of people have come up with ways to integrate taking a medication into their daily routine. Some people will you know, decide to take it every, the same time every day, and so they’ll sort of attach it to something that they do on a routine basis, like brushing their teeth at the same time every day. Keep their pill bottle there. Other people might use a pill, might have a medication pack that they carry around with them, and set an alarm on their on their calendar or on their smartphone to remind them every day.
Dr. Jonathan Shuter:
But you have to also anticipate other situations. What are you going to do when you go on vacation? The time to think about it is not when you’re running to the gate in the airport. The time to think about that is the day before. What should I do? Where should I pack this?
Or, if you’re going to go sleep at a friend’s house for the night and be out of your house for 24 hours. How can you take the pill along in a way that works for you, because if you don’t think of those things in advance, they’re not going to happen, and your adherence is going to fall down, and when PrEP fails, it is because patients don’t take their pills right. So please give that some thought. If you’re contemplating starting prep, or you’re on it now, think about how to stay on it really, really, reliably, over the course of time.
What if you Miss a Dose
Transcript:
Dr. Jonathan Shuter:
This medicine only works if you take it and take it as you’re supposed to. But what happens if my routine is to take it at 8 am, every morning. And then one day at dinner time, I realized I didn’t take it, I didn’t take my 8 am dose. That’s scenario number one.
Scenario number two is, what if I miss a whole day? You know I missed my Thursday dose? And here’s Friday, and am I still protected? And what should I do? Should I double dose? Or what’s the correct approach?
Dr. Uriel R. Felsen:
That’s a great question. And you can imagine that this comes up all the time, and nobody’s perfect, and nobody is going to be expected to take their medication at the exact same time every day, 365 days a year. So this definitely comes up and we have to have real world expectations of our patients. And so the idea is, you want to do the very best that you can. So let’s say you take your pill. Let’s say you’re on Descovy or Truvada, and you take your pill every day at the same time at 8 am.
And come that evening, you realize you haven’t taken it yet? Go ahead and take it, and that’s it, you’re going to be just fine. You’re within the same 24 hours. It’s it’s just fine. You’ll be able to take your next pill at 8 am the next day without having to worry about it.
That would be for the first situation that you said.
If you entirely missed a day, don’t double up on your meds. If you missed your Monday dose, and now you wake up on Tuesday and said, Oh, my God! I forgot to take it. Take your Tuesday dose, forget about the Monday dose. It should be all right. Everyone is, you know, the idea is to take it as consistently as you can, and we want to make sure that you take it almost every day. But if you miss a day. It’s not worth the potential risk of having too much medication on board by doubling up that day.
Stopping or Restarting PrEP
Transcript:
Dr. Raffaele Bernardo:
So obviously things, life, circumstances, change, relationships come and go, and so can PrEP. People can stop and start PrEP as they feel is necessary. However, we do recommend it is done under the guidance of a healthcare provider, for a couple of reasons.
In terms of discontinuing PrEP. Dr. Felsen had alluded earlier about checking for underlying hepatitis B infection prior to starting PrEP. The same is true when you stop PrEP. If it was missed initially and again, just to remind everyone, the reason is because these oral forms of PrEP do have activity against hepatitis B as well.
And if an infection is missed, and these oral forms are stopped, you can actually have a rebound infection and can develop fulminant liver failure. And so we do have to screen, if it wasn’t screened for initially. If someone does have chronic hepatitis B, they do need to remain on at least one form of hepatitis B medication that that individual can discuss with their provider
In terms of restarting. PrEP, again, similarly, things change and people can definitely restart. However, prior to restarting prep, you do need an HIV test to make sure that you are, in fact, HIV-negative before restarting PrEP. So you should never just keep the pills at home, decide to stop for a month or two and then pick it up, you know two, three months down the road without discussing with the healthcare provider, because those tests do need to be repeated, and to make sure we aren’t missing anything.
When it comes to the injectable form of proper aptitude, there is an additional concern. Apretude does have a very long what we refer to as a tail, meaning that after the injection it does take a while before the medication is completely eradicated from the body. And the reason this is concerned is because if someone does have an HIV exposure during this quote unquote tail period, they may still get infected, they may still get HIV. But now, because you have that low level drug available in your system, the HIV virus can become resistant to that medication, and not that we couldn’t treat the HIV infection. But we have to be a little bit more creative with our medications.
So that’s an additional nuance in terms of starting and stopping PrEP when it comes to the injectable. Not that someone would do this at home, since it has to be done in the healthcare provider’s office, but something to keep in mind. If you stop injectable PrEP. If you feel that there may be a potential risk for HIV acquisition to make sure you’re using some other form of HIV prevention like condoms, for example, until you are able to return to your doctor’s office to discuss restarting injectable Apretude.
Pregnancy and PrEP
Transcript:
Dr. Uriel R. Felsen:
So Truvada is safe in pregnancy, where one partner is living with HIV and the other partner is not living with HIV, and sometimes a couple like that might be trying to conceive, and so Truvada is an option in that situation to help prevent acquisition of by the person who’s not living with HIV, and also to protect the fetus.
The injectable is relatively new. We don’t really have enough information about cabotegravir in pregnancy. At this point, if you are on Cabotegravir and you become pregnant, you’d want to discuss with your provider the options of either staying on it or potentially switching to Truvada. That would be a discussion to have.
But people who are on Truvada can continue that through pregnancy.
Dr. Raffaele Bernardo:
So the two things I was going to add, one is right, so these are medications like Truvada, for example, that we’ve been using for a very long time, particularly with people living with HIV who get pregnant. So we have a lot of good data showing its safety profile in the setting of pregnancy. The other thing I will add to what Dr. Felsen mentioned is that while Descovy is safe in pregnancy, it typically is not, or it should not be a medication that we would be giving for HIV pre-exposure prophylaxis in somebody who is capable of getting pregnant. And the reason is because it is not FDA-approved for people who engage in receptive vaginal sex. So again, while it is safe in terms of the fetus, it is not a medication that somebody in that situation would be prescribed prior to getting pregnant. Presumably.
