Human Immunodeficiency Virus Book

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HIV Preexposure Prophylaxis

Aka: HIV Preexposure Prophylaxis, HIV Pre-exposure Prophylaxis, HIV PrEP
  1. See Also
    1. Human Immunodeficiency Virus (contains epidemiology information)
    2. HIV Presentation
    3. HIV Course (HIV Stage)
    4. AIDS-Defining Illness
    5. HIV Complications
    6. HIV Risk Factor
    7. HIV Screening
    8. HIV Screening Questions
    9. HIV Transmission
    10. HIV Exposure
    11. Sexually Transmitted Disease
    12. Bloodborne Pathogen Exposure
  2. Definition
    1. High risk adult HIV prevention protocol
  3. Precautions
    1. High risk of noncompliance and secondary Antiretroviral resistance
      1. Compliance is critical (must take daily to prevent HIV resistance)
      2. Does not replace safe sex practices (Condoms)
    2. Financial costs are very high for Truvada in addition to periodic labs and clinic visits
      1. Very expensive ($1300 per month and $14,000 per year)
    3. Risk of Renal Failure, liver toxicity, Osteoporosis
  4. Indications
    1. HIV negative adult (over age 18 years) AND
    2. Understands and consents to risks and benefits of therapy AND
    3. Able to comply with strict daily medication adherance and follow-up with HIV Test every 3 months AND
    4. Very high risk of HIV Exposure
      1. HIV positive partner (or partner at high risk with unknown status)
      2. Sexually active in high HIV Prevalence region or social network
      3. Inadequate Condom adherence
      4. Has Sexually Transmitted Disease
      5. Illicit Drug use or Alcohol Dependence
      6. Sex worker or barters for sex
  5. Labs
    1. HIV Screening
      1. PrEP requires negative results of current HIV Screening protocol (fourth generation testing as of 2014)
      2. Repeat HIV Test every 3 months
    2. Sexually Transmitted Infection screening
      1. Increased risk of HIV Transmission with comorbid Sexually Transmitted Infection
      2. Repeat every 6 months
    3. Hepatitis BVirus testing (xHBsAg)
    4. Serum Creatinine
      1. Onset (avoid starting if Creatinine Clearance <60 ml/min)
      2. Repeat 3 months after starting
      3. Repeat every year
  6. Contraindications
    1. HIV positive status (or unknown status)
    2. Non-compliance or unable to comply with monitoring
    3. Age under 18 years of age
    4. Lactation
    5. Pregnancy
      1. Relative contraindication - may be continued with Informed Consent
    6. Creatinine Clearance <60 ml/min
      1. Relative contradindication
  7. Management
    1. Ongoing HIV preventive counseling
      1. Behavioral risk reduction
      2. Condom easy access
      3. Pregnancy status monitoring
      4. STD Screening and management
    2. Antiretroviral therapy
      1. Requires strict Medication Compliance (medication must be taken everyday, not simply before intercourse)
      2. Patient should be aware that Truvada costs $1300/month (as of 2014)
      3. Emtricitabine 200 mg and Tenofovir 300 mg (Truvada) orally daily
    3. Immunizations
      1. Hepatitis B Vaccine
  8. Efficacy
    1. May reduce HIV risk by 92% if Truvada is taken daily
    2. Prevents one case of HIV in 44 Men who have Sex with Men each year
  9. Adverse Effects
    1. Antiretroviral therapy adverse effects
      1. See Truvada (Emtricitabine with Tenofovir)
      2. Start-up syndrome (Nausea, Abdominal Pain, Flatulence, Headache) which typically resolves after the first month
    2. Hepatitis BVirus flare
      1. Associated with abrupt cessation of Antiretroviral therapy
    3. Acute Renal Failure
      1. Risk when Truvada is combined with multiple dose or high dose NSAIDs
  10. Prevention
    1. See HIV Transmission Prevention
    2. Use Condoms to further prevent HIV and other STDs
  11. Resources
    1. CDC HIV Pre-exposure Prophylaxis Information
      1. http://www.cdc.gov/hiv/prevention/research/prep/
  12. References
    1. (2014) Presc Lett 21(7): 41
    2. (2012) Presc Lett 19(8): 44
    3. Baeten (2012) N Engl J Med 367:399-410 [PubMed]
    4. Sherin (2014) Am Fam Physician 89(4): 265-72 [PubMed]

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