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How I Approach PrEP in Practice
How I Approach PrEP in Practice

Released: October 14, 2022

Expiration: October 13, 2023

Jason E. Farley
Jason E. Farley, PhD, MPH, ANP-BC, FAAN, AACRN
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Key Takeaways
  • Shared decision-making between patient and provider is the most effective way to implement HIV PrEP.
  • A holistic, nonjudgmental view of the patient’s sexual health helps to “de-medicalize” HIV PrEP, reduce anxiety, and increase adherence.

With the release of new guidelines for HIV pre-exposure prophylaxis (PrEP) in late 2021, healthcare providers are now tasked with implementing relevant changes within their clinics. Effective PrEP hinges on patient adherence, and I have found that a shared decision-making approach between patient and provider yields the most successful outcomes.

When a patient comes in thinking about starting preventative HIV therapy, the first thing I do is say, "Perfect, let's do that." Then I ask them to talk about why they think HIV PrEP might be right for them. I then continue this dialogue by asking them to provide a more holistic view of their sex life with the main focus being on sexual pleasure, not disease or disease prevention. We then discuss how HIV prevention can be integrated into their life so as to promote their well-being.

This approach “de-medicalizes” treatment and empowers the patient to discuss sex openly and to be proud of the decision to take control of their HIV prevention, while simultaneously shifting the focus of HIV PrEP from a disease-specific frame to one of sexual health. Recognizing that patients can be concerned about their health while still engaging in acts of sexual pleasure destigmatizes the treatment process, reducing anxiety and increasing HIV PrEP adherence.

Monitoring Viral Load
Although we are seeing how effective HIV PrEP can be when properly administered, viral load evaluations remains the key to early HIV diagnosis and prevention of resistance. Testing for HIV RNA levels should be performed for all patients on HIV PrEP during clinic visits—every 2 months for long-acting injectable cabotegravir (LA CAB) PrEP, every 3 months for oral PrEP.

Here’s an example of why monitoring is crucial. I was a coinvestigator on HPTN083, a Phase IIb/III study examining efficacy of injectable PrEP in HIV-uninfected cisgender men and transgender women who have sex with men. I had a married heterosexual male patient who participated in this study, and his sexual history screening revealed he was having sex with men outside of his primary married relationship with his wife. During a clinic visit, the patient tested positive for syphilis, and I ordered an HIV RNA test as both infections tend to go hand in glove. At the time of syphilis diagnosis, he had no HIV RNA present. One week later, I found that his HIV viral load was 83,000 copies/mL.

This case study reaffirms the guidelines that HIV viral load monitoring should be performed alongside clinical care management, regardless of HIV PrEP efficacy. Following these guidelines leads to earlier HIV diagnoses, which in turn leads to earlier treatment and prevention of further viral transmission to sexual partners.

PrEP Options for HIV and STIs
As HIV PrEP becomes more accessible, it is important that clinicians explore all options for prescribing these medications, so that the most effective regimen can be matched to the patient. There are currently 3 PrEP options for most folks, but only 2 for cisgender women. It is the responsibility of the clinician to provide an overview of the pros and cons of each so that patient-provider shared decision-making can occur.

In addition to HIV PrEP, data from other trials suggest that doxycycline, when taken as post-exposure prophylaxis (PEP), is effective at reducing other sexually transmitted infections (STIs) such as gonorrhea and syphilis. The CDC has stated that doxycycline PEP may be an effective method for preventing STIs, especially when combined with HIV PrEP. Thus, although the efficacy of doxycycline PEP has yet to be thoroughly evaluated, I have just begun having routine conversations with my HIV PrEP patients about this doxycycline strategy. Healthcare providers should continue to monitor relevant clinical trials in these areas, as guidelines are likely to change.

Insurance
A key barrier to PrEP treatment remains variable insurance coverage and the need for medication assistance programs to fill this gap. The US government website “Ready, Set, PrEP” provides all the necessary details on assistance qualification, and I usually start with this site for my patients. Typically, we can find PrEP support for most patients who qualify.

Your Thoughts?
How do you approach sexual health, STIs, and cost when discussing HIV PrEP with your patients? Join the conversation by posting your comments.