Preparing Providers for Effective HIV Intervention: 5 Steps to Get “PrEPared for PrEP”
by Sonali Kulkarni, MD, MPH
Medical Director, Division of HIV and STD Programs
County of Los Angeles Department of Public Health
Leo Moore, MD, MSHPM
Robert Wood Johnson Clinical Scholars Program
University of California Los Angeles
Since FDA approval in 2012, Los Angeles (LA) County has been at the forefront of expanding access to life-saving biomedical intervention pre-exposure prophylaxis (PrEP) for HIV prevention. Despite gradual declines in the annual number of new HIV cases over the past few years, approximately 1,400 County residents are still newly diagnosed with HIV every year.
Fortunately, the advent of HIV pre-exposure prophylaxis, or PrEP, is one of the most exciting recent developments in the field of public health. PrEP, available as a daily pill or bi-monthly injection, is a medication taken by individuals who are HIV-negative before they are potentially exposed to HIV and has been shown to reduce the risk of HIV acquisition by up to 99% when taken as prescribed and instructed. As of December 2021, the FDA has approved three drugs forPrEP: Truvada® (also available as generic), Descovy®, and Apretude®
While consumer knowledge about PrEP has increased, many healthcare providers still lack adequate knowledge about PrEP to maximize its potential to prevent new HIV transmissions in LA County. To help healthcare providers get “PrEPared for PrEP”, the County of Los Angeles Department of Public Health’s Division of HIV and STD Programs (DHSP) recommends providers use the following five key steps:
1. Familiarize Yourself with PrEP Guidelines.
In 2021, the CDC updated the PrEP Clinical Practice Guidelines to equip providers with comprehensive information for the use of PrEP to reduce the risk ofHIV transmission. These guidelines include, among other topics, an overview of clinical trials, indications for use, goals of PrEP therapy, screening labs, and special considerations for PrEP use.
The guidelines are very thorough and will likely serve as a future reference in your care for patients on PrEP, so it’s good practice to review them prior to discussing PrEP with your patients. In clinical practice, we’ve found that patients have many questions about PrEP during the initial conversation, such as “How does it work?”, “What are the side effects?”, and “Do I have to use condoms with this medication?”, and this document will help you prepare to address their questions.
2. Discuss sexual health with your patients.
Your patient’s sexual history is important to their overall health and wellness. A good sexual history will help guide your physical exam. Ensure you screen your patients for STIs in all the places they have sex (vaginal, anal, or oral), and establish your patients’ risk for HIV acquisition.
Use the “Five P’s”of sexual history: Partners, Practices, Protection from STDs, Past History of STDs, and Prevention of Pregnancy. (For a quick refresher, see CDC’s Guide to Taking a Sexual History.) Our comfort level as health care providers in asking sexual health questions can influence how comfortable our patients feel disclosing information about their sexual practices.
Based on the local epidemiology of new HIV cases, DHSP asks health care providers to discuss PrEP with all sexually active patients and offer PrEP to patients if they indicate the following:
- Has had anal or vagina sex in the past 6 months; and
- One or more partners are living with HIV or have an unknown HIV status; or
- Recent bacterial STI (syphilis in anyone is very highly associated with HIV risk)
3. Discuss PrEP with your patient.
If your patient is sexually active, inform them about PrEP. Based on our experience, the following are key talking points to help your patient understand how PrEP works:
- What is PrEP? – Medication (taken as a pill or an injection) that reduces the risk of getting Human Immunodeficiency Virus (HIV) before an exposure through sex or sharing
- Adherence – Explain that studies have proven the efficacy of PrEP. Explain that adherence is associated with how well the drug protects against HIV. When taken as prescribed, via an oral pill or bi-monthly injection, the medication is up to 99% effective in preventing HIV acquisition.
- Side effects – Most common side effects of oral PrEP medications include nausea or bloating, which usually improves after the first few weeks. The most common side effects of injectable PrEP include injection site reactions such as pain, redness, ors welling. Most patients can tolerate these if they are warned about it in advance. Different formulations come with other, less common side effects. For patients prescribed tenofovir disoproxil-fumarate/emtricitabine (Truvada), this includes a mild change of kidney function (decreased creatinine clearance), which usually normalizes after discontinuation of the medication. For patients prescribed tenofovir alafenamide/emtricitabine, less common side effects include weight gain and a slight increase in cholesterol. Consider shared decision-making when prescribing to patients who may have concerns based on previous medical history.
- Condoms– Condoms are still very important. Inform your patient that PrEP does not protect against STDs and that the best form of protection for these is condoms. Cases of chlamydia, gonorrhea, and syphilis (primary, secondary, and congenital) have all increased for the first time since 2006, which further highlights the importance of encouraging concurrent condom and PrEP use. If a patient reports decreased or no condom use after starting PrEP, this is not a reason to withhold the medication. Instead continue PrEP due to his or her elevated risk and continue to screen for STDs and provide education.
- Signs of acute HIV infection – Inform patients of signs of acute HIV infection such as a flu- or mono-like illness, fever, or diarrhea. If these symptoms develop, they should return to the office as soon as possible.
4. Complete Screening Labs & Review Medical Contraindications.
Screen patients for HIV, STDs (using urine GC/CT, pharyngeal GC and/or rectal GC/CT testing based on reported sexual behavior), Hepatitis B and Hepatitis C, kidney dysfunction, and pregnancy (if applicable).
Screening patients for HIV involves assessing them for symptoms of acute HIV as well as testing them for HIV. Advances in laboratory HIV testing mean that most large laboratories offer 4th generation testing, which can detect acute HIV. If patients who started on PrEP seroconvert, there is a risk that HIV can become resistant to the two drugs used in PrEP because it does not constitute a complete treatment regimen for someone infected with HIV. Fortunately, this has been shown to be extremely rare. DHSP recommends informing patients to return to care immediately to undergo repeat HIV testing if they develop acute HIV infection symptoms.
5. Start PrEP and Follow Up!
Once you identify a patient at elevated risk for HIV, make every attempt to expedite this process and initiate PrEP as soon as possible. Once you decide to prescribe PrEP to a patient, also make every attempt to expedite the process and initiate PrEP as soon as possible. Patients can startPrEP same-day if they’ve never been on PrEP before, pending an HIV 4th generation test. If test results are positive, patients should return for HIV care and receive proper antiretroviral treatment.
After initiating PrEP, patients should return every 3 months to assess for side effects and adherence as well as routine HIV, STD, and kidney function testing/lipid testing (depending on the prescribed medication).
Helping Patients Stay on PrEP
It’s important to inform your patients that PrEP is affordable and easily accessible. PrEP and all related medical services are 100% covered as preventive services. Services should be billed directly to Medi-Cal, not the patient’s managed care plan. PrEP is covered by Medicare with very low co-pays. Covered CA Plans cover the costs of medication and related medical services at no cost to the patient. Prior authorization may be required under Covered CA plans but must be expedited so patients can access medication quickly. Bronze Covered CA plans provide poor coverage for PrEP, so patients should consider this when purchasing a Covered CA plan. Most major insurance providers cover the costs of medication and related medical services at no cost to patients.
All of our County public STD Clinics offer PrEP and PEP, and can refer to one of over a dozen PrEP Centers of Excellence (COE) for ongoing PrEP care. For people who do not have insurance or are underinsured, a PrEP Navigator at one of the PrEP COEs can help you find a free or low-cost provider and enroll you in Medi-Cal or one of the Patient Assistance Programs below.
Directory of these centers can be found here.
For additional information, visit our dedicated PrEP website, getprepla.com.
- Grant RM, Lama JR, Anderson PL, et al.Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363:2587-2599.
- Baeten JM, Donnell D, Ndase P, et al.Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367:399-410.
- Thigpen MC, Kebaabetswe PM, Paxton LA, et al.Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med. 2012;367:423-434.
- Choopanya K, Martin M, Suntharasamai P, et al. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. The Lancet. 2013; 381(9883), 2083-90.