Prescribing 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.

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?

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.

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.

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 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.