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Incorporating New Clinical Recommendations on PrEP: From Guidelines to Clinical Practice
Incorporating New Clinical Recommendations on PrEP: From Guidelines to Clinical Practice

Released: August 01, 2022

Expiration: July 31, 2023

Latesha Elopre
Latesha Elopre, MD, MSPH
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There is a lot of excitement about the new CDC recommendations to educate everyone about pre-exposure prophylaxis (PrEP).

Providing Patient Education About PrEP

The new guidelines recommend that all sexually active adults and adolescents receive health education about PrEP. Ultimately, providers should ensure that the following key factors are incorporated:

  1. Assess sexual health and wellbeing during all patient visits
  2. Discuss appropriate PrEP modalities as indicated
  3. Ensure that discussions on sexual health are positive and not stigmatizing

However, very few patients know what PrEP is, how effective it is, the common side effects, and where they can access PrEP. Therefore, increasing PrEP knowledge is the next step to have the transformation we are hoping to see regarding the HIV epidemic.

An approach that many providers use to improve access and uptake of PrEP is taking a comprehensive sexual history in an appropriate and destigmatizing way. Another approach, which I think makes it easier for patients in our clinic, is not forcing them into face-to face discussions of intimate or personal questions about their sexual health, substance use, mental health, or intimate partner violence. Instead, like a lot of clinics, we collect these patient-reported outcomes through brief electronic questionnaires. Patients can complete these questionnaires before their visit or while they are in the waiting room, and healthcare providers can use the answers as a platform to discuss anything concerning. Alternative health delivery system patterns can increase your ability to ensure you are taking a universal sexual history.

New Guidelines on Monitoring While on PrEP

In my clinical practice, we had a committee discussion on best practices for the appropriate incorporation of the new CDC recommendations, specifically for testing patients during routine visits. It is recommended that a patient on emtricitabine (FTC)/tenofovir alafenamide (TAF) have a lipid profile evaluation. However, if hyperlipidemia or worsening lipidemia develops due to PrEP, providers are often unsure what the next steps should be. While CDC guidelines recognize that lipids should be monitored, they do not always provide clear recommendations on how to manage these issues should they arise.

We also incorporated the new recommendation to check viral loads. While we understand that there is a risk of getting a new HIV diagnosis while on PrEP, providers are concerned because the patient must have their blood drawn for viral load checks and this may deter or be a barrier for some patients. Coming in every 2-3 months to get PrEP in the clinical setting requires flexibility in the patients’ work hours, reliable transportation, and very good health insurance. Inadequate access to care can be a substantial barrier for the populations that are most vulnerable and disenfranchised. Accordingly, this requires providers to consider new and innovative ways to deliver PrEP that will remove burdens to patients.

Questions From Colleagues on Recommending or Prescribing PrEP

Although I enjoy recommending and prescribing PrEP, most of my colleagues are Internists with their own internal medicine clinics. Although many are very excited to hear about PrEP and want to prescribe it, they are not educated enough in providing PrEP care. For example, the frequency of visits and the testing associated with visits can seem overwhelming. My colleagues have mentioned challenges in shifting their workflow and routine clinical practice to incorporate discussions about PrEP with their patients when indicated.

An area of opportunity is working with early career providers and trainees who express optimism and excitement regarding PrEP updates. Teaching trainees, especially those entering primary care professions, how to effectively promote sexual health and prescribe PrEP may be a crucial next step in changing PrEP provision in the clinical setting.