PrEP Therapy for High-Risk HIV Candidates

Segment Description: Julia Marcus, PhD, MPH, discusses pre-exposure prophylaxis (PrEP) therapy and identification of high-risk patients appropriate for PrEP.

Transcript (modified slightly for readability):

Ian Frank, MD: We have to ask people what behaviors are they engaging in. I worry more, Allison, as you point out, that older folks are less likely to be asked these questions because assumptions are being made. The assumption is that they’re married; or they’re too old to have sex.

It’s not hard. You can preface the questions by saying, “I ask all my patients these questions.” So that already means: “I’m not asking you because I’m worried about you. I ask all my patients these questions. Are you in or have been in a sexual relationship? Is it with a man? Is it with a woman? Is it with men and women?” It’s not hard to ask these questions in 30 seconds and receive a lot of information. Also, if you are taking care of somebody whom you’ve been taking care of for a while and you have a trusting relationship with the patient, it’s not hard to ask these questions.

Colleen Kelley, MD, MPH: I think the most important thing is to routinize it, right? To make it a part of every single interaction you have with a patient. So then even if you were uncomfortable asking those questions, over time you’d become comfortable. If it’s just routine, you do it every single time.

Joseph Eron, MD: If you had a disease where the therapy could prolong your life for 30 years, would you want that test? I think so. That makes sense, right? Let’s talk about— Julia, let’s get into pre-exposure prophylaxis. Can you talk about this and how do we identify these patients? Then we can talk about what interventions there are.

Julia Marcus, PhD, MPH: Pre-exposure prophylaxis, or PrEP, is the use of HIV antiretroviral medications that have been historically used for treatment, instead using them for prevention. My favorite analogy for PrEP is birth control. That it’s generally a daily pill that you can take to prevent HIV if you’re at risk of acquiring HIV.

We can also talk about other ways of taking it. For some populations, just taking it around the time of sex, specifically for men who have sex with men, has been shown to be effective. We can also identify which patients are appropriate for PrEP.

Joseph Eron, MD: How do we figure that out?

Julia Marcus, PhD, MPH: Very similar to the indications for HIV screening in terms of HIV risk factors. HIV screening is recommended universally but in particular for people with HIV risk factors. The USPSTF [United States Preventive Services Task Force] and CDC have identified certain groups that are good candidates for PrEP, including MSM [men who have sex with men] men, who are sexually active and have a partner living with HIV, or who use condoms inconsistently for anal sex or have a recent STI [sexually transmitted infection]. It’s similar for heterosexuals, although STIs are really limited to syphilis and gonorrhea for that group, excluding chlamydia. And then for people who inject drugs, anybody who shares drug equipment or has any of the sexual risk factors.

Joseph Eron, MD: It’s my understanding that women, frequently women of color, sometimes underestimate their risk. That’s a problem.

Allison Agwu, MD, ScM: When we think about how the CDC reports how women acquire HIV, they say a risk factor is women who are having sex with a high-risk partner. If you ask the question like that, of course they’re going to underestimate their risk, right? If you’re living in a high-risk zip code and you say, “Are you having sex with a high-risk partner?” “No, I have had 1 partner. No, I’m not.” However, just living in that zip code, your partner is at higher risk of obtaining HIV. We have to think about how we ask those questions and, again, routinize how we offer treatment, offer testing, and then offer PrEP. That is when people are going to put themselves in, “Oh, yeah, I could be potentially at risk.”

Colleen Kelley, MD, MPH: There are 2 things that are really important when you’re thinking about assessing someone who might be a good candidate for risk. The first thing is to understand your local epidemiology. Understanding what’s going on in your community, what does HIV transmission look like in your community. Are you in a place where there is high prevalence and new infections that are still turning up, like many places in the Southeast? Or are you in a place where you know there’s maybe not a lot of transmission ongoing?

And then identifying people who might be good candidates, either from having multiple partners or having condom-less sex with multiple partners who have had an STD [sexually transmitted disease] in the past that’s actually a transmitted infection. Those patients may be whom you first start the conversation with. But honestly, anyone who’s sexually active outside a relationship, in a monogamous relationship with an HIV-negative partner who wants PrEP, is a candidate for PrEP.

Joseph Eron, MD: Right, I think that’s good.