For Providers Interested in PrEP
These resources are intended to help you understand how PrEP can benefit your at-risk patients.
Thanks for your interest in this new strategy for HIV prevention. On this page, we have put together some answers to questions that providers often ask about PrEP.
We encourage you to take some time to review this information, but we realize your time is at a premium. If you’re in a hurry, we’d suggest reviewing the CDC’s PrEP page or their one-page fact sheet (PDF format) that provides very basic information about PrEP. You could also take a few minutes and watch this brief video from Dr. Christopher Hurt, a faculty member in the UNC School of Medicine’s Division of Infectious Diseases.
Providers’ Frequently Asked Questions
In 2012, the FDA approved an existing tablet called Truvada (true-VAH-duh) for use as PrEP among individuals at risk for HIV infection. This decision was made on the basis of several large clinical trials showing this strategy works well at preventing HIV infection among uninfected heterosexual men and women, men who have sex with men, transgender women (male-to-female transsexuals), and injection drug users.
Truvada is also used for treating hepatitis B virus (HBV) – so knowing the infection status of patients prior to initiating PrEP is important. If a patient who has HBV is started on Truvada and then discontinues it for some reason, s/he may experience a “flare” of hepatitis and can become ill. Though some evidence suggests Truvada may reduce the likelihood of acquiring HBV, it is not recommended for HBV prevention; vaccination is recommended for those who are susceptible based on serologic testing.
“Discordant” couples (one with HIV, one without) trying to conceive can also benefit from PrEP. If the HIV-infected partner is on treatment and her/his viral load is “undetectable,” and the negative partner is initiated on PrEP, the risk of the uninfected partner acquiring HIV is extremely small – perhaps even zero. We can help connect such couples with high-risk obstetricians for additional counseling and support, as well.
Adherence can be made easier by scheduling pill-taking with something your patient already does routinely – like eating a meal, brushing her/his teeth, or plugging in a cell phone before going to sleep. Setting an alarm on a cell phone or clock also helps some people remember.
Extended use of tenofovir (one of the two agents in Truvada) has two adverse effects that are important to consider for patients who might be on PrEP long-term:
Nephrotoxicity. About 10% of HIV-infected patients taking tenofovir have slight elevations in serum creatinine. You don’t have to stop the drug, provided that the estimated creatinine clearance (eCrCl) remains at or above 60 mL/min. Although no patients in clinical trials of PrEP developed more severe renal impairment, we do sometimes see this in HIV-infected patients on Truvada long-term. Rarely, patients have developed proximal (type 2) renal tubular acidosis with or without the Fanconi syndrome (loss of glucose, phosphate, and bicarbonate into the urine). If you suspect renal injury, stopping tenofovir is recommended. Cessation of the drug allows for recovery of renal function for the majority of people.
Loss of bone mineral density. Within the first 6 months of taking tenofovir, at least 25% of patients on long-term tenofovir therapy have a small but measurable loss of bone density. This then stabilizes over time. Baseline bone densitometry is not routinely recommended unless otherwise clinically indicated.
• Call to determine eligibility, toll-free at 1-855-330-5479, M-F, 9A-8P EST
• Click here to download and fax the application directly from the Gilead website
To date, there have been no reports to the “watchdog” website MyPrEPExperience about insurance refusals from private companies or state Medicaid programs, though pre-authorizations may be required before the prescription will be approved.
• patient age
• risk factor for HIV acquisition
• date(s) and results of all available HIV tests
• date(s) and results of most recent serum creatinine level
• date(s) and results of most recent syphilis, gonorrhea, and chlamydia testing
For urgent or time-sensitive questions, call the North Carolina AIDS Training and Education Center (NCATEC) Clinician Line at 1-855-862-2832.
As a backup, you can also call the Carolina Consultation Center and ask to speak with someone from UNC Infectious Diseases. The phone number is 1-800-862-6264. Between 8 AM and 5 PM on weekdays, you’ll be speaking with an attending physician; after hours and on weekends, you’ll be speaking with one of our fellows (who can reach an attending physician quickly, if needed).
For non-urgent or general questions, please feel free to email one of our providers who has agreed to provide clinical guidance for PrEP. Please allow up to 48 hours for a response.
There’s No Shame in Being PrEPared: Embracing Pre-Exposure Prophylaxis
Christopher Hurt, MD
Whose Job Is It? Hint: Look in The Mirror
David Wohl, MD
Additionally, in June 2014, NCATEC hosted a webinar with Mitchell Warren, the director of AVAC, a non-profit organization dedicated to supporting efforts in HIV prevention and education.