Getting PrEP to the patients who need it
A fraction of those eligible for PrEP to prevent HIV infection receive a prescription. Newer drug regimens and updated recommendations can help you reduce that gap.
PRACTICE RECOMMENDATIONS
› Perform routine screening of patients for preexposure prophylaxis (PrEP) eligibility. B
› Prescribe oral or intramuscular PrEP for eligible patients after screening for HIV, other sexually transmitted infections, and hepatitis B, and establishing baseline renal function. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
PrEP use in specific populations
Adolescents
Truvada, Descovy, and Apretude all are now approved for use in adolescents weighing ≥ 35 kg. Two important considerations when prescribing to this population are the effects of Truvada on bone health and the unique barriers to access.
In studies of adolescent MSM using Truvada for PrEP, bone mineral density declined, especially among those ages 15 to 19 years.15 As such, the clinical impact of decreased bone mineral density should be weighed against the risk for HIV acquisition; however, bone mineral density monitoring is not recommended in the current guidelines. CDC guidelines suggest considering Descovy for male adolescents given its potential lower impact on bone mineral density.5
Confidentiality and legal issues exist when prescribing PrEP to minors. In terms of parental/guardian involvement, clinicians who are prescribing PrEP for patients younger than 18 years should consult the CDC website for guidance on local and state regulations that govern prescribing and confidentiality (www.cdc.gov/hiv/policies/law/states/minors.html).
Insurance billing statements may lead to inadvertent disclosure of a minor’s decision to take PrEP to their legal guardian.16 Generic Truvada costs less than $100 for a 3-month supply when using goodrx.com, which may offer an alternative to insurance for medication payment.
Peripartum patients
The increased risk for HIV acquisition in the peripartum period for female patients is well documented.17 Guidelines recommend offering PrEP with Truvada to female patients at risk for conception, currently pregnant, or breastfeeding when that patient’s partner has HIV and the partner’s viral load is unknown or detectable. Descovy is not recommended for pregnant or breastfeeding patients.5 Cabotegravir-containing regimens (Apretude) have not been approved by the FDA for pregnant or breastfeeding patients.5
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