Putting PrEP into Practice (Journal prompts medical professionals to respond to a PrEP hypothetical)

Published: March 20, 2011

Putting PrEP into Practice — The Experts Respond

Two experts describe how they would manage our latest Antiretroviral Rounds case.

Last week, we described a high-risk young man seeking intermittent pre-exposure prophylaxis (PrEP) for HIV infection and asked whether you would be likely to prescribe PrEP for him. Of the nearly 400 people who responded to our poll, 45% said they would not prescribe PrEP, 35% said they would prescribe intermittent PrEP, and 20% said they would prescribe continuous PrEP. Now, two experts describe what they would do.
The Case

A 29-year-old man goes to the emergency department (ED) to request post-exposure prophylaxis (PEP) to prevent HIV infection. He has just returned from a week-long vacation, during which he had unprotected oral and receptive anal intercourse with several men whose HIV status he does not know. His last HIV test was 6 months prior to this ED visit, and the result was negative. He reports no medical problems and is not taking any medications. He receives a 28-day course of tenofovir/FTC + lopinavir/ritonavir PEP.

Four days later, the patient has a follow-up visit with his primary care provider (PCP), who is aware that he has received at least three similar courses of PEP during the previous 4 years. His HIV antibody test has again returned negative. He says he is aware of when he is going to put himself at high risk for HIV infection (usually during vacations and particular weekends) and would like a supply of tenofovir/FTC to take during these periods; however, he does not want to take the drugs continuously.

If you were the PCP, what additional history would you obtain? Would you try to change the patient’s high-risk behavior? If so, what specifically would you say to him? Would you recommend tenofovir/FTC pre-exposure prophylaxis (PrEP) for him? If so, would it be continuous or intermittent? How frequently would you monitor for HIV, other sexually transmitted infections (STIs), and tenofovir/FTC toxicity? If you would not prescribe PrEP, what is your reasoning?

First, do no harm
Carey R Terry, UT Family Practice Memphis, 1 Mar 2011 9:57 AM EST
Competing interests: None declared
Specialty: Family Medicine

Though it is reasonable to expect that this type of prophylaxis will hasten the senescence of tenofovir, drugs are to be used not horded. My belief is that it is the job of the Physician to perform the title function of the profession, namely to teach. After that the patient decides how they will use the informaiton.

Pre-Exposure Prophylaxis
Marc A. Tanenbaum, 1 Mar 2011 11:26 AM EST
Competing interests: None declared
Specialty: Pediatrics

My concern about PreP is that it creates an illusion of safety and implies that with PreP in the absence of condom adherence the patient is protected during risky sexual behaviors. This is a high medical liability area for the practitioner to practice in. Better to not prescribe PreP than to face future medical liability issues. I’ll leave it to the specialist to accept this risk while I continue to counsel my patient on condom use and avoid risk behaviors.

Pre-exposure prophylaxis
d h, 1 Mar 2011 1:43 PM EST
Competing interests: None declared
Specialty: Family Medicine

Prescribing pre-exposure prophylaxis for a high-risk behavior to an apathetic person is like purchasing ammunition for a repeat bank robber. This patient needs a counselor.

PrEP decision and consequences
Joalie E Davie, Santa Fe, NM, 1 Mar 2011 2:36 PM EST
Competing interests: None declared
Specialty: Unspecified

How does one set healthy boundaries and manage the care of a patient with an addiction? Since his behavior is detrimental to his well being and he does not seem to be in control of his behavior and puts his health at risk, I treat it as an addiction. I believe, it is best is for the patient to learn to behave more responsibly and avoid the risk on infection to HIV and other veneral diseases by using condoms and by decreasing exposure risk. First I would try to educate the patient about all the risks of unprotected sex which include numerous infections for which there is no prophylaxis and for the risk of developing resistance to the anti-viral agent used for repeated and frequent use of PrEP and ending up with no prophylaxis and just side effects. Second I would refer the client to a therapist practicing hypnosis and or energy psychology to release the blocks this patient has to using a condom and to clear him from his propensity to engage in behavior that puts him at risk for disease and morbidity. I would agree to give him prophylaxis for up to 3 months on the condition he also follows through my other recommendations. Should he refuse to get therapy, then I would give him enough prophylaxis for 1-2 months and recommend he that he chooses another health care provider.

Patient autonomy
Tom Boyles, South Africa, 1 Mar 2011 7:55 AM EST
Competing interests: None declared
Specialty: Infectious Disease

Check HBV status and vaccinate if negative, check creat. Advise TDF/FTC to be taken 1 weeks before and 4 weeks after potential exposure. Warn of the risks, toxicity, resistance if he is infected, only around 40% effective (condoms much better), risk of transmitting resistance. Let him make an informed choice. Monitor Creat after first 4 weeks on continuous therapy.

Sorry no HIV prophilaxis, rather change risky behavior.
James Voigt, MD, Allegiance Family Medicine North, 1 Mar 2011 9:16 AM EST
Competing interests: None declared
Specialty: Family Medicine

I would not recomend HIV prophilaxis for ongoing risky behavior, rather that risky behavior needs to change or else my patient would end up going the way of Magic Johnson. I would encourage safer sexual practices.

reason for not prescribing PrEP
P F, Ireland, 1 Mar 2011 9:41 AM EST
Competing interests: None declared
Specialty: Infectious Disease

To justify prescription to one individual sets a precedent whereby this should be prescribed to all who seek it. This intervention would need further evidence of value from a population health point of view before it could be justified.

PrEp
Suhash Patel, 28 Feb 2011 8:44 PM EST
Competing interests: None declared
Specialty: Internal Medicine

PrEP gives patients the idea that risky behavior can be in part "safer" with these medications. I believe as healthcare professionals who identify high risk behavior it is our job to help change it rather than condoning it. While PrEP may be a good idea, I do not believe I would prescribe it to any of my patients.

Putting PrEP into Practice
Dr Murugan Sankaranantham, Tirunelveli- India, 28 Feb 2011 8:51 PM EST
Competing interests: None declared
Specialty: Dermatology

Dear Sir, I would not prescribe TNF/FTC as PrEP as no PrEP is 100% foolproof. If one acquires HIV inspite of PrEP, then this patient may not be able to take a regimen containing the wonderful NRTI backbone of TNF/FTC as it likely to become resistant. This will be more dangerous when the individual takes PrEP repeatedly. This should not happen to this good drug. Moreover in future, as he is promiscuous, he is likely to acquire HIV at any time and at this juncture this drug may become useless. Even for repeated PrEP also the usefulness of the drug is questionable. There is every chance for this resistant strains to TNF/FTC is likely to be transmitted to his contacts in future. Then it is a big social problem. So I do’nt use TNF/FTC as a PrEP drug.

PrEP
monchai siribamrungwong, Lerdsin General hospital, 1 Mar 2011 8:14 PM EST
Competing interests: None declared
Specialty: Internal Medicine

PrEP for this situation, may be harmful. According to the PrEP is designed for HIV prevention after accident, not for the attention event like this. Not only it can not complelely prevent from resistant HIV infection or other STD infection but also the risk of side effect and drug resistance should be concerned. I think frequent administration of prophylaxis may be harmful for him.

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Double Standard?
Melissa Dattalo, 2 Mar 2011 5:40 PM EST
Competing interests: None declared
Specialty: Internal Medicine

How is this different than prescribing a PPI for heartburn when a patient refuses to give up coffee or a statin for hypercholesterolemia when a patient will not make dietary modifications. Our business is to prescribe medicines to mitigate risk when people do not (for whatever reason) make healthy lifestyle choices.

Why I would not prescribe
John GILBERT, 4 Mar 2011 2:51 PM EST
Competing interests: None declared
Specialty: Family Medicine

Not being an expert in STI, I would refer to a specialist. However, I would like to know what evidence there is – how is the HIV risk modified by PrEP? If the evidence is there, he should have his prescription on the grounds of harm-reduction. If he got infected, can you imagine what a hazard he would represent to his contacts?

Putting PrEP into practice
Musa Abubakar Garbati, KFMC, Saudi Arabia, 5 Mar 2011 5:54 AM EST
Competing interests: None declared
Specialty: Infectious Disease

A. Additional info. 1). Condom use. 2). Heterosexual partners. 3). Partner(s) also on PrEP?. 4) Chances of changing his behavior? B. Will advice on risk reduction behaviors. C. For PrEP, it’s Tenofovir that’s recommended and not TDF/FTC D. Monitor every 6 months for HIV and other STIs as symptoms dictate. Also to monitor renal function which a major prblem with TDF. E. I will prescribe PrEP, using TDF only with ongoing counselling to reduce risky behavior and reduce number of partners. To advice his partners also to go for HIV and STI screening.

PrEP
Olumuyiwa Akingunola, Abeokuta, Nigeria, 6 Mar 2011 6:24 PM EST
Competing interests: None declared
Specialty: Family Medicine

I think the previous doses of PrEP doses is reinforcing his risky behaviour. he will go on to have HIV if he will not stop those behaviours.

**Responses received up to 22 March 2011.

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