PrEP For Doctors

Welcome to “Is PrEP For Me”: The Doctors’ Edition.

In this video series, I want to share as much information as I can about PrEP. Not only about what PrEP is and how it works, but also who it’s for, how to prescribe it and how to continue prescribing it. As a caveat, I just want to say that I am based in Melbourne, Australia, and the information that I’m sharing on this website is particular to Australia. There are many great resources for other sections of the world and this information is just as relevant around the world. However, I am focusing in on particular laws and particular ideas that are for Australian doctors. I hope you find this really helpful. If you have any questions, please by all means contact me and I’ll do my best to make sure that I get a great answer for you.

What Is PrEP?

What is PrEP? PrEP is a medical intervention that helps reduce the risk of HIV infection in people who are at risk of HIV infection. It’s a tablet, and when taken every day, it can reduce the risk of HIV by up to 99%.

How Effective Is PrEP?

How effective is PrEP? We know that when taken every day, the chances of HIV infection are greatly reduced. Looking at the studies, we can see that when taken every day reliably, the chance of HIV infection is reduced by approximately 99%. There is always a minor risk of infection, and this is an important point that you do need to make sure you go through carefully with your patients. 

Who Is A Good Candidate For PrEP?

Anybody who at medium to high risk of HIV infection is a good candidate for PrEP. This can include people who are in a serodiscordant relationship, i.e., the person considering going on PrEP is HIV-negative and their partner is HIV-positive. Other people include men who have sex with men, who inconsistently use condoms; people who use methamphetamines or injectable drugs; people who are exchanging sex for commodities, whether that be money, accommodation, food or safety; or, people who are having sex with people who may be in these categories. The most important thing to be aware of is that people need to be aware of the potential risks, side effects and consequences of going onto PrEP. However, if they’re happy, keen and looking for ways to help reduce their risk of HIV infection, PrEP is a fantastic thing to be discussing.

PrEP Only Protects Against HIV

PrEP is only effective against HIV. It does not affect any other sexually transmitted infections. For this reason, it’s really important that you reinforce the idea of regular sexual health screening, as well as the use of condoms and their ability to help reduce the transmission of STIs as well.

How Does PrEP Work?

How does PrEP work? PrEP is a combination of two drugs: Tenofivir and Emtricitabine. The way it works is it stops HIV’s ability to create the second strand of RNA that is later used to enable replication within the T cells. When taken every day, Truvada, the combination of the two drugs, actually stops HIV from being able to replicate and take hold within the body.

Common PrEP Side Effects

What are the common side effects of PrEP? PrEP is actually quite a robust medication and it doesn’t have a huge amount of side effects. Probably the most common side effect is on initiation it can cause some abdominal side effects. This includes for some people constipation, for some people loosening of the stool, and for some people bloating. What I can say is that it doesn’t happen with everybody and when it does happen, it’s usually gone within one to two weeks. There’s a number of ways that you can help reduce this risk and that includes things like taking the medicine with food, adjusting the time that you take the medicine, and sometimes acidophilus yoghurt. Anything that helps the gut biome can help reduce the effects of this particular outcome.

Rare PrEP Side Effects

Reduced Renal Function

PrEP does have some rare side effects that are very important to follow through with. The first one is that in some people, PrEP can reduce the function of the kidney. For this reason it’s very, very important that when you’re starting PrEP, that you have a very careful examination of the patient’s medical history. Are they diabetic? Do they already have preexisting kidney disease? Are they on medicines that can affect renal function such as metformin or frequent doses of NSAIDs that could reduce the function of the kidney?

We also test kidney function. If you have a patient whose eGFR is less than 60, it is important to talk with a HIV specialist before initiating PrEP. We do know that occasionally, there can be a slight reduction in eGFR in our patients. We do know that when stopped the PrEP, the eGFR does tend to return back to normal. However, if you notice any concerns, worries or changes in kidney function, it’s important to have a talk with a competent, confident, PrEP prescriber or HIV specialist to discuss options and the best way to deal with these particular issues for your patients.

Reduction In Bone Density

In some people there have been concerns about bone density and the risk of fracture when taking PrEP. This is actually an extremely rare side effect. What we can say is if you have patients with pre-existing bone density issues or they are at high risk of osteopetrosis, it is worthwhile to consider a bone density scan before they start PrEP. Remember there are a number of different ways that we can help optimise bone density in our patients. This includes regular calcium rich foods, weightbearing exercise, regular access to the sun, as well as checking your vitamin D levels and supplementation, if their vitamin D levels are low.

Contraindications For PrEP

What are the contraindications of going onto PrEP? The number contraindication to go onto PrEP is that the person is already infected with HIV. For this reason, it’s very important at the beginning of the screening process that we do a test for HIV. We’re looking for HIV-1 antibodies, HIV-2 antibodies, and if we can use a fourth generation that checks for p24, this greatly reduces the window period. If somebody has had a potentially high risk exposure to HIV a month before they’re considering starting PrEP, it’s worthwhile to carefully monitor their status to make sure that the person has not had an exposure and infection with HIV beforehand. If the potential risk and exposure to HIV is within 72 hours, it’s worthwhile talking with this patient about going PEP or post-exposure prophylaxis.

Renal Disease

Other contraindications to go onto PrEP is kidney disease. If a person has an estimated GFR less than 60, PrEP needs to be initiated very carefully. It’s worthwhile having a conversation with a HIV or PrEP specialist before starting PrEP.

Initiating PrEP in Hepatitis B Positive Patients

If a person is living with hepatitis B, PrEP can lead to an increase in hepatitis B viral load when the medicine is ceased. For this reason, if you have a patient who has been infected with hepatitis B, it’s worthwhile talking to a HIV specialist or PrEP specialist before initiating PrEP.

Initiating PrEP

The First PrEP Appointment

What do you do in the first appointment when you are wanting to start somebody on prep? What I do in the first a conversation with the personal about their particular risk of infection with HIV. You need to be … You need to be pretty pointed actually and work out, why does this person want to go on prep? Is it because they’re actually at genuine risk of HIV infection? That is, they’re not using condoms, they’ve had recent episodes of rectal chlamydia, gonorrhoea, or syphilis. Or that this is a person who is in a particular lifestyle that means that they just aren’t using condoms reliably. This is a person who would definitely benefit from prep. Some people want to go on prep because they’re particularly worried about HIV. That’s okay. I talk to them about the potential side effects and their potential … Their own potential risk of HIV. And then it’s up for the patient to be able to balance those out. But you need to able to provide as much information as you can to enable the patient to make a decision that’s ideal for them.

It’s important you go through the potential side effects of prep, and the pros and the cons. You need to explain to them how to take the drug, what to do if they could miss a tablet, and ways to deal with that, and also how to start taking the drug. And also if they choose to go off the drug, how to stop taking the drug. Once you’ve done all of those sort of things, it’s important to then organise the testing. What I like to do is I do a full sexual health screening. I also check their kidney function, phosphate to see how everything’s going there, and also check their status for hepatitis A, B, and C. If their not immune to hepatitis A and to B, I do recommend that they get a vaccination for those. And hepatitis C, if it comes back positive, they do need to organise that treatment as well, but do not let that stop them starting on prep.

You then need to go through the legal aspects of importing prep into Australia, and I’ve done a video on that below. What I’d do is that I’d do the HIV test and if it’s negative, that’s great. When the person’s drugs arrive, I get them to come back and it’s an opportunity to one, check that the drug that they actually ordered the right stuff. And also to be able to talk to them about how to take the drug, remind them of side effects that could when they start. And also, it’s a chance to do a second HIV test to confirm that they are HIV negative, and to inquire about whether or not they’ve had any potential exposures to HIV since you last saw them. It’s important that when you’re starting prep that the person is absolutely HIV negative. If they’ve had any potential exposures to HIV, they should be able to start the prep, but you will need to very carefully monitor their HIV status over the next couple of weeks to be 100% sure that they are not [seera 00:02:59] converting or within the window period of HIV.

Medication Review Before Starting PrEP

It’s important to have a review of people’s medications before they start PrEP. Any medicines that could affect renal function are worthwhile making sure that everything is okay. Examples include people who are on ACE-inhibitors, people who are on metformin, or who regularly use [inaudible 00:00:20], all of these drugs can affect kidney function so it’s important that you review these medicines as well as making sure that their kidney function is okay. These are not contraindications to starting PrEP. However, it is good to know where you are starting from and if you are going to be adding any of these medications whilst the person is being treated on PrEP. It’s worthwhile to carefully monitor renal status during this process.

For this reason, I like to make sure that I have all of the information for my patients. Sometimes patients may only come to you for PrEP but they may have another GP. It’s important to be able to talk with your patients about the importance of continuity of care and all doctors having access to this information, not just for yourself, but also for the other practitioner as well. I understand that there are some patients who are worried about confidentiality in situations like this. However, their health is vital so it’s important that you reinforce to these patients that somebody or both doctors have to be in complete communication to make sure that everybody is aware of all medicines that are being taken.

PrEP Pre Screening Tests

The screening tests that I like to organise before starting PrEP include: I like to check kidney function. We need to know that the kidneys are working well and that they have an estimated glomerular filtration rate of more than 60. This is also a good opportunity to review a full sexual health screening. This includes a throat swab for chlamydia and gonorrhoea, a rectal swab for chlamydia and gonorrhoea, a urine test for chlamydia and gonorrhoea, and a blood test to check for HIV, syphilis, and it’s a great chance to check hepatitis A, B, and C status. In addition, as mentioned before, it’s important to check the renal status, perhaps a full blood count, have a look at phosphate, and if somebody is at potential risk of osteoporosis it might be worthwhile considering vitamin D status as well. If you have a patient with established osteoporosis or who is at high risk of osteoporosis, it may be worth considering getting a baseline bone density scan before starting PrEP.

High Risk Exposures Before Starting PrEP

If you have a patient who there may be a risk that they have been exposed to HIV one month before initiating PrEP, I like to organise a second appointment to confirm HIV status before the person starts taking the medications. My normal flow would be that I organise the full screening tests, and if the patient is importing medications, what I do is I bring them back when their medicines have arrived. This is a chance to discuss how to take PrEP, but also to do a second HIV test to confirm that they are HIV-negative.

HIV Positive Test Results As Part Of PrEP Pre-screening

If you discover that a person is HIV positive during the screening process of starting PrEP, the most important thing is do not start PrEP. PrEP is not appropriate for this person, this person needs to be on HIV treatment which involves three agents that are active against HIV. Truvada or PrEP only has two agents and it’s important that we offer full, effective, potent treatment for HIV in people who have recently been diagnosed with infection.

Guide For Patients on PrEP

Helping People Take PrEP Every Day

How do you guide people on how to take PrEP? Currently the recommendations in Australia are that PrEP is taken every day. What I’d like to talk to my patients about is to find something that they do on a regular basis and tie taking the medicine to that. Say, for example, if they take another medication in the morning, that’s a great time to take PrEP as well. Or, if they regular do something like brushing their teeth before they head out for the day, make sure that they put the PrEP next to the toothbrush. It’s a great reminder, ah, I’m brushing my teeth. Awesome, I’ll take my PrEP at the same time.

For some people, say, for example, shift workers or people who have a slightly more chaotic lifestyle, what I recommend is that they perhaps get an app in their phone or set a regular alarm that reminds them to take their medicine. Some people tell me that they forget whether or not they took their medicine. In cases like this, I recommend a dosette box where they put out all of their medicines once a week. That way they can be 100% sure they’ve got a visual reminder that tells them whether or not they took their medicine.

Use Of Condoms While On PrEP

One of the more common questions for people who are going on to PrEP is, does this mean that I can stop using condoms? We know that condoms have a role in all sexual health, not just HIV prevention. Taking PrEP every day does greatly reduce the risk of HIV infection. Adding condoms into the mix can also help reduce the chance of transmission of some STIs. However, it is important to know that we understand that people are going on to PrEP because the condom is not always used when it comes to sexual encounters. However, we can encourage that as part of a full comprehensive sexual health protection that condoms can be a useful part of this.

Regular Screening For PrEP: The Quarterly Visit

My General Flow For The PrEP Follow Up Appointments

The general flow for my follow-up appointments is that I have a conversation with my patients about any side effects, any issues that they’ve had with taking the PrEP. I do ask about missed tablets because a good opportunity to help reinforce ways that they can be more compliant with taking their medicines. It’s also a really great chance to just see how they’re going.

I ask if they’ve had any diagnosis with sexual infections, because sometimes people will go to other doctors with STIs and have them treated there. If this person has had a sexually transmitted infection, it’s a great time to document this in the chart.

I also ask if the person has any current symptoms of STIs. If they have any penile discharges or discharges through the vagina or cervix, it’s a really good chance to be able to make sure you get a swab of that discharge to find out exactly what is going on.

With the conversations done, I’ll produce a new script with the reinforcement of how to order the drugs online and reminding them that they do need a script every three months and that they are not to import more than 90 days worth of tablets at a time. Also, I like to document which version of generic Truvada the particular person is using, whether it be Ricovir-EM, Tenvir-EM, or Adco-Emtevir: the three main generics that I recommend.

Scripts aside, conversations aside, it’s now time to do a full sexual health screening. If they have any questions, you’ll be able to answer these quite efficiently. A lot can be done in a simple 15-minute appointment.

Discussing PrEP Side Effects

Follow-up appointments for PrEP are fairly straightforward and can be done in a systematic way in a 15-minute appointment. The first thing I like to do is have a conversation with the patients about how everything is going. Have they had any issues with the medications? In particular, are they having any side effects, and particularly, are there any side effects that’s stopping them from being able to take the medicine?

Gut side effects are quite common and for this reason, I do recommend that they trial taking the medicine either with food or at slightly different times. People who get nausea after taking the tablet, I sometimes say, “Why don’t you try taking it at night before you go to sleep?” That way, if the nausea comes, they may be asleep while it’s happening and they may miss out on that particular side effect. What we know is that this particular side effects does tend to wane quite quickly.

Very occasionally, I have had some patients who have developed unusual rashes while taking PrEP. I’m not 100% sure of these mechanisms, but it does seem to happen infrequently. Again, this seems to be a minor side effect that does go away. However, remember, when a person is seroconverting, round about 70% of people during the seroconversion to HIV-positive can get a rash. This is a very important point in time to do a full sexual health screening and to check their HIV status. I would do that as a part of a fourth generation antibody test and include P24 as well.

Routine Quarterly Sexual Health Screening

Some people can be at risk of sexually transmitted infections as is everybody who is sexually active. Every three months it’s a perfect opportunity to do a full sexual health screening and this includes a throat swab for chlamydia and gonorrhoea, a rectal swab for chlamydia and gonorrhoea, a urine test for chlamydia and gonorrhoea, and a blood test to check for HIV, syphilis and hepatitis C. I also check renal function at this time as well.

My STI Screening Workflow:

The system that I like to use is quite straightforward when it comes to the sexual health screening. After I’ve had the discussion, created the new script then I usually follow with, okay, let’s get the sexual health screening going. I’ll get you to grab a seat with your legs hanging over the side of the bed. With the person sitting on the side of the bed, this is when I do the throat swab, a good chance to inspect the inside of the mouth to see if there’s any pus and to also do the swabs. Remember both sides of the tonsillar bed and one across the back. If they gag, you did it right.

Technique For Chlamydia / Gonorrhoea PCR Throat Swab

At this point, I instruct the patient, “I’ll get you to lay on your side facing in towards the wall.” I know that many doctors often will send their patients off to do their own rectal swabs. I am a believer in doing the swabs ourselves, and the reasons are it ensures that the swab is done properly, but also it’s a good opportunity to inspect the anus to see if there are any other things going on for example, a syphilitic chancre, anal warts. Remember that men who have sex with men are at significantly higher risk of anal cancers. If they’re HIV-negative, it’s 40 times the risk. If a person is HIV-positive, it is 100 times the risk. This is an opportunity to discover anal cancer before it’s significant. I really do recommend that you do your own anal swabs to make sure that you are not missing anything.

After the swabs are done, I give the urine container to my patients and send them off to the bathroom with the instructions we just need the first part of urine that comes out of your body. We don’t need gallons. We just need about half the jar. Then, I often will send them off to the blood or to if you’re in a place that has pathology on site, you can get the pathology to do the blood test or you can take the blood yourself, package them all off and send them off.

Urinary Tract STI Screening: Gonorrhoea & Chlamydia

In an asymptomatic person, a urine test for Chlamydia, Gonorrhoea, PCR, is best done. They say to have at least two hours since the last episode of urination. We want to get the first part of urine that comes out of the body. If a person has a pustular discharge, it is worthwhile to also do an additional gel swab to be able to do MCS to make sure that there is no resistance, in particular, for Gonorrhoea.

If A Person Has A Positive HIV Result While On PrEP

If you discover that one of your patients has returned a positive HIV result while they’re on PrEP, it’s very important to get in contact with a HIV specialist doctor immediately. Talk to one of your local sexual health specialists and work out the best strategy to dealing with this case as it is. The biggest risk for HIV seroconversion when a person is taking PrEP is if they have not been able to take the drug on a regular basis. For this reason, it is very important at every appointment to reinforce that it is important that the drug is taken every day. You need to take it every day to ensure that there is a high enough concentration within the T cells to clock HIV replication.

Importation Of PrEP

Explaining How To Import PrEP

When I talk to patients about how to import the drug, I personally take them to the PrEP Access Now website, http://pan.org.au. I walk them through the process. Key points that I want to remind them about is that they should never import more than 90 tablets at a time. I also want to reinforce to them that as part of the process of ordering online, they will need to take a photo of their prescription and upload it to the website so they can legally import the drug into Australia. I also remind them to keep their script. Should customs ask them any particular questions when the drug is coming into Australia, they’ll have their script and they’ll be able to say, “This was prescribed by my doctor. I’m importing this legally.”

Helping Patients Comply With PrEP Importation Laws

What is the legal status of importing PrEP in Australia?

It is perfectly legal to import generic Truvada into Australia. However, there’s some things that we can do to help ensure that our patients are compliant with the law. The first thing is that we have to provide the prescription for the patient to be able to bring the drug into Australia. Patients need to have been prescribed this by their doctor. Now, importing any drug into Australia, it’s important to know that you cannot import more than 90 days worth of medications into Australia. When you create the script, you must only ever write the script for 90 tablets and no repeats. I’ll reinforce this again: 90 tablets only, no repeats. This works out very, very well because we want the patients to be coming back every three months for a full sexual health screen to check their renal status and also to touch base and see how they going with the medications. 

Choices For Generic Truvada

Sometimes people are confused with the generic versions of Truvada. The three main generics that I do recommend is Tenofivir-EM, Ricovir-EM, or Adco Emtevir. These three are the main options that are provided under licence from Gilead and these are manufactured in a number of sites across the world. However, to help ensure compliance and to help get the patient into a regular routine I like to recommend that they go with one particular type and order the same each time. It just reinforces the same medicine, the same tablet every day. Pan.org.au is a fantastic website with plenty of great information, as well as the current pricing and recommendations for importing generic Truvada into Australia.

PrEP Tips & Tricks

Helping Compliance In PrEP Treatment

After discussion on any particular issues with the tablet, I like to make sure that the person is having any problems in being able to take it every day. This is a really good opportunity to be able to talk about different strategies to improve the ability for a person to take the tablet daily, whether that be setting up dosage boxes, calendars, phone reminders. There are many, many ways to help ensure that our patients are taking the tablet every day.

What If A Patient Misses A Tablet?

If a person misses an occasional tablet of PrEP, it’s not a huge impact on the efficacy of the drug. The most important thing is that we want to reinforce that people take the tablet every day. An occasional missed tablet is not going to greatly reduce the protection against HIV. The protection against HIV infection drops off significantly, when people are taking less than four tablets a week. In patients who are struggling to take the tablet on a regular basis, it’s great to be able to have some time to brainstorm ways to help ensure that this person can get into a routine of taking their tablet every day.

If somebody misses a tablet, they don’t need to double up the next day. Also, some patients are worried that if they have a particularly highly active period of sex, that they should double up on their medicines. This is not the case. A single tablet every day is the effective dose. There is no need to increase the amount of medicine taken, if there is an increase in sexual activity.

Thank you For Your Interest In PrEP

Doctors, I have covered a lot of information. If you have particular questions, please send me a message, and I will do my absolute best to make sure that I get an answer for you. I want to make sure that you are not left wanting for any information.

This is an organic site. I want to continue adding to this site, updating this site, and it’s your feedback that will help me ensure that I am answering all of your questions. So, please send me an email, DrGeorgeFS (at) gmail and I will do my absolute best to get an answer directly to you, and to also update this site and make sure that it’s got the best information for you.

I wish you the absolute best, and I’m always happy to answer any questions you may have about prescribing prep for you patients. I wish you the absolute best, and thank you for your interest in helping reduce HIV infections in Australia.

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