Welcome To Your Guide For PrEP, PEP, & HIV Prevention

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. 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.

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.

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.

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.

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. 

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.

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.

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.

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.”