Sammi: Good evening everybody and welcome to this evening’s Prescribing HIV PrEP in General Practice (Part 3), and tonight we will be focussing on managing positive STI and HIV results. My name is Samantha and I am your host for this evening. Before we get started, I would just like to make a quick Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past and present.
So, that brings us to introducing our presenters for this evening. So, we are joined by Dr Brad McKay. He is our facilitator for this evening. Brad is a general practitioner at East Sydney Doctors in Darlinghurst and is an HIV S100 prescriber. He was the host of Embarrassing Bodies Down Under, TV presenter and medical advisor for the Today Show and Today Extra on Channel Nine and host of the HIV podcast Praxhub.com.
And Dr Nathan Ryder is our presenter for this evening. Nathan is a sexual health physician with 15 years of experience in HIV management in urban and rural Australia. He is the Clinical Director of Sexual Health for the Hunter New England Local Health District, and the HIV Support Program coordinator for the Hunter New England LHD also. And Conjoint Senior Lecturer at the Kirby Institute, UNSW and the University of Newcastle. So thank you Brad and Nathan for joining us this evening.
Brad: Thank you very much, Samantha.
Sammi: I will hand over to Brad now for our learning outcomes for this evening.
Brad: Cool, no problems. Well thank you everyone for joining us tonight. My name is Dr Brad McKay and I will be facilitating the webinar. Nathan is also here as well. Hi, Nathan.
Nathan: Hi Brad.
Brad: Your dog is not barking in the background anymore?
Nathan: I think that might have been the kids.
Brad: Oh, no. Well welcome everybody to the third webinar on our series in preventing HIN with pre-exposure prophylaxis, otherwise known as PrEP. So, for those of you who are re-joining us, welcome back and for those of you who are here for the first time, thank you so much for taking the time tonight to learn about this very important topic. So previously, just recapping, in webinar 1 we discussed the basics of prescribing PrEp. In webinar 2 we discussed how to take a sexual health history when assessing a patient for PrEP and you will have access to both of those webinars on the RACGP website as well. And tonight in webinar 3, we will briefly review PrEP prescribing and then focus on what to do if a patient has a positive HIV result. And I remember back in the day when I was not working in HIV and had a few patients who had a positive result and I really did not know what to do, so I am very happy to be here and telling everybody else what the process is and making sure you are all fully supported.
So we will just go to the next slide here. So, this is a bit of a reminder about our strategy across New South Wales and around the world. So there is an international strategy to virtually eliminate HIV transmission by 2020. Yes, they made that a while ago and 2020 is coming up pretty quickly so we are trying to reach those marks, and if we are going to be able to eliminate HIV transmission, we are needing a coordinated effort with everybody including all of you. So the New South Wales HIV strategy has been designed to help us all do our part in eliminating HIV and we will be going through all of that. But a vital part is really using PrEP. So using one pill a day to prevent HIV transmission. This needs to be rolled out at a very large scale and so we are needing everybody to be on board. This is not just for specialists, GPs everywhere can prescribe PrEP and that is one of the big messages from today. And one of the other things to remind everybody is do not throw away your condoms yet, all of my patients ask me that. We still continue to advocate for condoms because they can still protect people from HIV and they are still good for protecting against other STIs as well, as PrEP will not stop you from getting gonorrhoea.
So, we will go here. So, HIV pre-exposure prophylaxis. We will sort of run through the basics of it that we have done in the previous webinars, but just a bit of a refresher. So, PrEP involves taking one pill a day to prevent HIV transmission. So, every pill of PrEP contains two different medications and they are highly active against HIV replicating in the human body. So these two drugs are in that box there. They are called tenofovir disoproxil fumarate and emtricitabine which you do not want to say after a few drinks. So, any doctor can prescribe it as I said. The streamline authority approval number if you are still writing hand written scripts is 7580. And it is available from community pharmacies. So, a lot of pharmacies that I work with will have it available straight away, but some of the pharmacies around Australia may need to order it in. So there might be a 24 hour delay.
So, PrEP is commonly known as Truvada and that is what is sort of in the media. That is how people talk about it all around the world. It is also known as tenofovir EMT or tenofovir disoproxil emtricitabine mylan. There are a few generic brands around. People have known it as the little blue tablet to protect people from getting HIV, but now some of the generics are actually coming out as teal, or green. Nathan have you been seeing those tablets pop up at your clinic?
Nathan: I have not actually heard people talking about the colour to be honest, but yes I mean, I suppose if they are generic they are going to look different.
Brad: It is freaking some people out, but they are coping okay. It is just a slight colour variation. But, yes, if somebody is a resident in Australia and holds a current Medicare card, it is available under the PBS and it has been available on the PBS since the 1st April of this year, and yes it is really important that every GP is able to prescribe PrEP. So if you do have patients coming in to talk to you about it, that you are not sending them down the street or making more and more hurdles if they are already having the guts to talk to you about their sexual life, and then if you do not know what to do or if your colleagues at work do not know what to do, we really want to decrease those barriers and stop there from being any hurdles for people getting access to it if it is appropriate for them.
So, so please note that you can prescribe PrEP for people who are HIV negative and this is quite easy. We will go through that for you today. But it is still tricky to treat patients who are HIV positive. We have had some questions on previous webinars and different talking events around, saying if HIV prevention is so easy, isn’t HIV treatment so easy? But there are a few little twists and turns and if you are wanting further training which I would highly recommend, you can do the S100 highly specialised drugs training program for HIV. So I have done the course. I actually did it twice. It was weird, I am a bit of a geek. But, yes, you can certainly get on board and do that and learn a little bit more about HIV. It is a really fascinating area.
So, just come to the screen here. So this is prescribing PrEP clinical tools. And I think we will be sending an email to everybody with this as a handout or as a pdf, I should say. So, the PrEP prescribing pathway, this is a tool that has had a lot of thought involved into it. It has been created by ASHM, the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, which is why I really only call it ASHM. And it is to make prescribing as easy as possible for everybody. So it is available on the ASHM website too, and the pathway is pretty simple and we will move through the first sort of four steps relatively quickly. As I said, these are on the webinars previously. And then we will focus on what happens if your patient does come back with a positive result later on.
So, let us look first of all at step one. So assessing risk of HIV. So, this is talking about behavioural eligibility. So this means if you are trying to figure out if a patient would likely benefit from taking PrEP, you need to work out if they are at medium or high risk of getting HIV in the first place. So, to do this you need to ask your patient some pretty personal questions about their sex life. Even though I worked on Embarrassing Bodies Down Under, I am still a bit of a prude at heart, and I always take a big deep breath before launching into my sexual health history with any of my patients. And I have sort of written down like a bit of the language that I use with my patients just there on the right side of your screen. So, I will often say, well I sort of say to everybody, are you having sex with men, women or both? I said that to a patient today and he was a straight male and he just looked shocked at me, and I just sort of said, look I ask this to everybody and then he just sort of giggled and laughed and then he was fine. So, if you are having it as a routine and it just sort of pops out, and you are just having it as run of the mill, most people will be able to respond to that pretty easily. So, I sometimes ask are any of your sexual partners living with HIV or are they HIV positive? Are you usually top, bottom, or versatile? Most gay men or bisexual men will know what you are meaning by that. So top being the insertive partner, bottom being the receptive partner. Do you use condoms? Often people will say yes and that gives you the opportunity to say are there times when you do not use condoms? And so that just gives people a bit of permission to be honest with you, and yes, it sort of, as long as you are running through it very, very regularly and just letting it role off your tongue then things get a lot easier over time. So, and as I said if you are wanting further information on sexual health history taking, then our second webinar is the place to go. So certainly check that out on line.
So I will hand over to Nathan, Dr Nathan Ryder who is going to run through some common scenarios where your patient might benefit from being on PrEP and how to identify that. So, Nathan over to you.
Nathan: Thanks, Brad. So yes first we are going to run through what I think is a pretty realistic scenario of Mo. So Mo is a 32-year-old male who presents to your practice and he asks for an HIV test. So obviously having seen the previous seminars you will know that at that point we need to do a bit of a risk assessment and so you ask him the sort of questions you just went through, Brad. And so we establish that he sometimes has condomless anal sex with a few known male partners. So he mainly uses condoms but there is a group of people that he knows that he does have condomless anal sex with. And that is a pretty common scenario. So you ask him a bit more about that and he thinks that his partners are HIV negative but he does not actually really know 100% when they were last tested. So he is not really sure about that. And so he says the last time he had unprotected sex was about eight weeks ago. So, if we have a look at the tool from ASHM and New South Wales Health around assessing PrEP. So we see that the man with male partners who is having condomless anal sex with partners who is not 100% sure are HIV negative, that would be a situation where you would be recommending PrEP. So it does not actually say on the slide there, but it would make a little bit of a difference whether he will be the receptive or the bottom partner, or the insertive partner, and even whether he is circumcised or not. So the receptive or bottom partner is the highest risk and we would strongly recommend Mo start PrEP. Whereas if he was insertive and circumcised, that would be a much lower risk. We would recommend it but we would not be as strong about it and probably a little bit dependent on the context and the frequency and that sort of thing. But certainly Mo meets the criteria.
Brad: Yes. So Nathan, with him saying that he thinks that his partners are HIV negative, being Devil’s advocate, is that enough? Would you trust what they are saying?
Nathan: Look, I mean that is not black and white, but a general rule in that scenario where there is you know, a few partners and he does not know exactly when they were tested and that sort of thing, we would probably get him to think about well, just exactly how sure is he? And the majority of people then on reflection think, well I think so but I am not actually really sure. And in that scenario most people really are at risk. I mean of course there are some scenarios where it might be long term, two partners neither of whom have other partners and they know exactly when they were tested. In that scenario, you know, may be. But the majority of the time if they do not know, then the answer is there may well be positives.
Brad: Yes, okay. Well we will move on to the next case here. So we have Mercy. Go for it, Nathan.
Nathan: Sure. So a slightly different scenario here. So Mercy is a 28-year-old female and she has been in your practice for a while now. So she comes in about an upper respiratory tract infection and asks you for a medical certificate. And so in the context of that, it just comes up that her and her husband have been trying for a baby recently. And you know the husband is living with HIV. So I guess you delve into that a little bit further and you establish that whilst her husband has been prescribed treatment for HIV that he does not always take that medication. So in that scenario, we need to think about well, what would be her risks of contracting HIV in the context of someone with HIV that is not taking their medication? So, sorry Brad were you going to ask me a question?
Brad: So with this, like just going back a step. How, if he is not taking his medication regularly, like how irregularly does he need to be taking it for it to be a problem?
Nathan: Yes, look that is a great question. So generally, what we are aiming for with people is 95% adherence to their medication to be confident that they have definitely got an undetectable viral load. But it is going to be a little bit dependent on the context again, and so if he is having large gaps, if he is not filling his scripts, if he is not getting his blood tests done, then you would have to err on the side caution and assume he may well have like a detectable viral load and hence be infectious. If you are just missing some here and there but are having all these tests and they are always undetectable, in that scenario I would be happy that he is not able to transmit. So it is really, it is really more about the engagement and care and regularity of taking the tablets. So 95% missing about one dose in a three month period, which is pretty hard right, most of us do not meet that barrier, so it is a little bit more forgiving than that.
Brad: Yes. So there she is thinking about trying for a baby. So we are presuming that she is not wanting to use condoms during that time. So, would you recommend PrEP for Mercy?
Nathan: Yes, so in terms of HIV discordant couples were one is positive and one is negative, so there is really two ways of going about that safely. So the first way is that the positive person is on treatment with undetectable viral load. If that is not happening, and sometimes that does not happen for a variety of reasons that are outside the control of the negative person obviously, then in that scenario we would definitely recommend PrEP. And it is commonly used for that. So we know that the Truvada that we are using for PrEP is safe in pregnancy. If you look up the rules around it, pregnancy is a caution around it, so this is something where you might get some specialist advice. But generally if we are looking at the pros and cons and the risk benefit relationship we would definitely recommend that Mercy takes PrEP while she is attempting to conceive. She may also want to think about timed intercourse. So in that scenario she would go to the chemist and buy a test to detect the LH surge and then she can tell when she is ovulating and they may choose to have unprotected sex at that time only. But not everybody does that obviously and being on PrEP would make it safe at all times.
Brad: Yes and there are many people who have been pregnant and using the same medication as PrEP, so Truvada over a long period of time. I suppose in this scenario, would you sort of suggest that once she does get pregnant that she would stop PrEP straight away? Is that one of the other strategies involved?
Nathan: Look I guess again, it is going to be weighing up the risks right? So, if she did not need the PrEP any longer then whilst you know, we are confident Tenofovir is safe and we recommend it for women that are HIV positive having a baby, you would not use a medication if you did not need it. So if she was confident that she was not going to have any unprotected sex for the rest of the pregnancy, I would recommend she stop. If she did occasionally have unprotected sex, then the risk to the baby would be that much greater so I may well recommend she continues it through the course of the pregnancy to protect both her and the baby from transmission.
Brad: Yes, and there is a question coming through as well and if you are listening, we are happy to take your questions on board as well. So please type them into the question box. How often would she need to get tested during pregnancy for HIV? Interesting question, Nathan.
Nathan: Yes, look I mean I do not think there is a particular guideline around that so you can only really be guided by her level of risk. I certainly would want to be testing her, if she was having unprotected sex then she needs to be tested every three months if she is on PrEP. So that would be the minimum I guess. If she was not taking PrEP and she was being exposed more often then you might even test more often than that. But you would probably use it as a basic rule, once every three months.
Brad: No worries. We will move on to the next case as well. So Nathan, over to you.
Nathan: Sure. So this time we have got Ronnie. So he is a 45-year-old Aboriginal man who presents to your practice and he actually asks you about PrEP. So he has heard about it from a friend, the most common presentation we get, and he is thinking well I might need to be on PrEP myself. I have actually seen many cases that are exactly what is on this slide. So he came with his husband and his husband is living with HIV. But his husband might see another doctor in your practice and he has been on medication for many years and he has always had an undetectable viral load, has absolutely no troubles with his medication. So, you talk to him a bit more and you establish that they are mutually monogamous, they do not have any other sexual partners. And so then we can have a think about well, does Ronnie need PrEP in this situation? And so this is quite different to the one previously. So we know that the husband is virologically suppressed, we know he is adhering to treatment and we know he has regular monitoring. So we are confident that he has an undetectable viral load and therefore cannot transmit. So you may have seen U=U which is undetectable is untransmittable. So we are very confident about that now, so I would explain to Ronnie that no, he does not need PrEP, that he is not at risk while he does not have any other partners. And that the risks of PrEP, whilst they are very, very low, would outweigh any benefit that he might get from it.
Brad: Yes, I suppose it is a tricky situation sometimes if you are explaining U=U. So if somebody has an undetectable viral load and they are unable to give it to anybody else, then yes, a lot of people want a bit of a backup option. So I suppose this could be a bit of a difficult conversation. Have you had patients who are still very prudent that they are wanting to be on PrEP?
Nathan: Yes, look we have got patients that still continue to use condoms even though the partner is virologically supressed and we certainly have some people that are on PrEP in this scenario. It is generally people where the relationship might not be as strong, where they are not really 100% sure and they just do not want to take that risk, which is hard for you as an external person to discount. It is not your relationship. Another scenario might be where they know the partner has drug and alcohol problems and whilst they mainly take drugs they sometimes do not. And so yes, there are scenarios where a situation might be quite similar to Ronnie but you may err on the side of prescribing. Another situation where we do commonly use it is in early diagnosis. Of course there is a short period of time between diagnosis and the viral load becoming undetectable, where PrEP is definitely indicated. But some people continue it a little bit longer than is probably strictly necessary because it takes them a bit of time to get used to that. And so I am reasonably lenient in interpreting this, because of course a lot of the time you may not necessarily have the results of the partner. So you are taking, you know you are not, you cannot see that they have got undetectable viral load. The patient is telling you that their partner does. So there is a bit of leeway I think there in terms of PBS criteria.
Brad: I think if somebody is coming in with their husband and saying, oh well yes we are monogamous, yes, yes. They may not be behind the scenes and that might be another ulterior motive for them to want to participate with PrEP even though it is not particularly indicated in that situation. So is also, yes, it pays to get them by their own and ask a few more questions than come in as a couple.
Nathan: Yes, I could not agree more. I think this is a situation where you certainly want to try and have a conversation separately and I would definitely – that would be 100% required if they were seeing me. Even if it was just when the other one was out of the room collecting some samples or something just to see, sound it out and see if there is anything. The other situation is sometimes, I have had partners where the positive person is really stressed out about transmitting to the negative person, and they are sort of pressuring the negative person to go on PrEP when the negative person is not actually worried about it. So yes, trying to balance that, sort of how the relationship can impact the consult is really quite important.
Brad: Yes, and I suppose the other thing to add as well is just, if they do decide not to go on PrEP this time, also reminding them that if their relationship changes or their situation changes, that it is certainly worthwhile coming back to it and looking at it again in the future if that is appropriate down the track.
Nathan: Totally. And also if they start PrEP they can stop. That you know, it is not a once-only decision.
Brad: Yes. Well we will move on to the next part, so clinical eligibility. So steps 2 and 3. You have to summarise all this, Nathan.
Nathan: Sure. So once we have established that our patient meets the criteria for PrEP, so we would be recommending it to them, so next thing is to decide if from a clinical standpoint that they are eligible for it. So really, that is made up of two things. So firstly confirm that they are HIV negative. So that in practice means that we have physically seen a negative HIV test within the last seven days and if that does not exist, then we repeat it. And then confirming that they do not have any signs of acute infection. And that is particularly the case if they have had a recent risk, which is not an uncommon scenario if you think about it because many people will come in for PrEP because they have taken a risk recently. They have then Googled it or they have spoken to their friends and thought oh, I really should have been on PrEP so I will go in. You have to always bear in mind, they could well have a risk within the window period and you need to think about seroconversion.
So the second part of it, so once you know that they are negative is assessing their renal function. So what we are looking for is, normal renal function is defined by an eGFR of above 60. If they are above 60 but below what you would expect for their age, you would still normally prescribe PrEP but you would probably look into it a bit more closely around that and just make sure you have got maximal control of their renal function and looked at any reversible factors there. So, so long as they meet them they are basically eligible. So in terms of interactions there are very few interactions with tenofovir to be honest. The main one is we do not really want someone on a seriously nephrotoxic medication. So not every medication in MIMS that says it can affect your kidney function. Things that are you know, significantly nephrotoxic and the two most common ones that we have had are high dose non-steroidals and lithium. And in both those situations, if the drug is required, then of course they continue it. We generally just monitor the renal function a bit more closely and make sure that they are aware of the need to avoid any additional particularly over the counter renal medications. At that point, they are clinically eligible.
Brad: Yes, there is one question coming through Nathan saying what are the risks of PrEP and how common are they? I suppose you are mentioning the nephrotoxicity, how common is that with PrEP?
Nathan: Yes, well it is actually really uncommon. So we know from HIV-positive people that have been taking PrEP now for probably 20 years, we know that tenofovir does have some degree of impact on the kidney. But in people who do not have HIV and do not have existing renal function issues, it is actually very uncommon to get a significant impact on their eGFR. So you may get some sort of decline and if you do fancy renal function tests you can see some degree of impact on the tubular cells. But we have not really seen any clinically significant impact. And the cases where it does happen generally it tends to be reversible, where you can stop it. But that said, you do need to warn people that it can affect their kidneys and if they have existing renal dysfunction and especially if they are older, then it can be potentially clinically significant in that scenario. The other issue is bones. So it can affect the bone cells and lead to osteopaenia. Again, in the context of an HIV-negative healthy person, that has not been clinically significant and we certainly have not seen any change in osteoporosis rates or fracture rates, but if you do do DEXA scans you will see a very slight clinically significant decline which is mainly reversible if you stop it.
Brad: So there is another question here too, just commenting on the base line tests at the initial consult. The question is, why are we doing an anti-hepatitis A virus test? Why do we need to check for hep A?
Nathan: Yes, great. So yes, so the other part of the slide there is, so after we have established they are clinically eligible, so we do some other assessments there. So that is not solely around the PrEP, that is more around the context of the situation in which you are starting PrEP. So if you are starting someone at high risk of HIV on PrEP, then you need to look at other infections as well that they might be at risk of. So for all gay men, we recommend that they are vaccinated or checked for past immunity to hepatitis A because there have been hepatitis A outbreaks in gay men and particularly in highly sexually active gay men which is generally the PrEP using group. So hepatitis B, so again we recommend testing, screening and vaccination for hepatitis B, but there is a special need in PrEP because if someone has chronic hepatitis B, so is antigen positive hepatitis B and they are stopping and starting PrEP, because tenofovir is the hep B agent as most of you will probably know, then there is a risk of inducing a flare with stopping and starting. So it is not a contraindication, but it will need to be a caution for them, particularly if they are e-antigen hep B about stopping and starting. Hep C again is just due to risk. So hep C is occasionally sexually transmitted so we want to make sure they are negative. So we are doing the eGFR mainly, but you are normally doing that in the context of EUC as part of their renal function test and then we are doing the full STI screen which for gay men will be throat swab, anal swab. Both can be self-collected. Plus the initial stream of urine, so not first void of the day but the initial 20 ml of any stream. Just as a full STI check. And we do that at baseline and we recommend it every three months.
Brad: Do you get your patients to do their own throat swab? Or do you get your pathology nurse to do it?
Nathan: So, actually I mainly do it myself because our clinic does not really work that way with the nurses. So some people collect it themselves, but actually very few. Most of them prefer you to do it themselves. I taught someone to do it only yesterday because he had been having his test at his GP and his GP had not been doing the anal swab and the throat swab, so I taught him how to do it so that he could then ask his GP, look I am happy to do it if you just give me the swab. He found that quite empowering that he could say that to his GP. But yes, basically if you get a mirror and you swab either posterior to the pharynx or the tonsils it has been validated as perfectly accurate. But the majority of people would just prefer you to quickly do it.
Brad: Okay. So I suppose yes just to clarify with the hepatitis A, if somebody has hep A and then somebody else is licking their anus, then that is one of the ways to transmit hepatitis A. So just to be clear about that and just to make sure that your patients are immunised against it. So, I just thought I would talk graphically about that point.
Nathan: So, yes just before we move on, so it is not on the slide there but in a female patient, you want to test for pregnancy. So again, not because it is a contraindication but more that you have got to manage it a bit differently.
Brad: Yes, if they have had unprotected sex then you want to make sure that they are not pregnant as well. Yes, okay. So we will move on to the next slide here. So I think this is still you, Nathan.
Nathan: Yes, sure. So once you have done all that assessment and so you are about to give them the scripts, we need to explain a few things to them. So, not on the slide there but the very first thing I would do because mainly you have not necessarily got that HIV test and eGFR back by the time you give them the script, because we normally join those two appointments together. So if I am giving the script and I am just taking the blood at that point, then make sure you call up and do not start the tablets until you get the negative test and the eGFR above 60. Okay? Or of course you could bring them back for that step, it is up to you.
So, around the, you know, the educational messages. So the main message is that you need to wait 20 days before you have protection. So many people they take the tablet and think great, I am protected, but it takes a while to build up those levels. So the guidelines recommend for both anal and vaginal sex to wait 20 days. Anal sex is a bit quicker. Some people recommend seven and the cervical vaginal levels of drug take a lot longer. It is just the way the pharmacodynamics work. So you definitely need to wait a full 20 days if you are female. The flip side, so if you are stopping, and people stop for a variety of reasons obviously, you need to tell them well look, you need to continue for 28 days after the last time you had unprotected sex, you cannot just stop straight away.
In terms of adherence, so using the normal strategies that you would for anyone else with a chronic disease, helping them think of ways to maintain that adherence, we strongly recommend daily adherence but we do know that it works with four tablets a week. We do not recommend people take four because it is very hard to remember four and then you have absolutely no leeway if you miss a dose. But if they miss the odd dose here or there it does not really matter. If they miss by 12 hours they can take it. If they miss by more than 12 hours, they just miss the day. And from a practical sense, you normally give them the script and they obviously take it to a pharmacy. The majority of pharmacies will not have it in stock. Some of the larger ones with a lot of people on PrEP do, but the majority will get it in, in my experience in the Newcastle and Hunter Region which is probably reasonably reflective of most areas outside central Sydney, the pharmacies can get it in within 24-48 hours at the most and we have not had any issues at all with it. It comes in packs of 30 and they generally have two repeats so it goes for 90 days between scripts.
Brad: Okay. So yes Nathan, there is just another question here about sexually transmitted infection testing. So, just to clarify for chlamydia urine test, does it need to be first in the morning with the urine? Or can you get it at any time of the day?
Nathan: Yes. No, it definitely does not have to be first in the morning. So that is, with the old chlamydia tests it did, but with the modern ones any part of the day is fine. The key thing is for a male it has to be the first 20 ml of the stream. So they start urinating in the jar, they finish in the toilet. With females it is actually not that important. It can even be midstream urine. That can work well. But yes it is not the first stream. Occasionally the lab will write that on the request, particularly in situations where it is a weird result and they think they might have missed it, they may recommend that, because that would slightly increase the sensitivity. But as a general rule no, you do not need to do that.
Brad: Cool. Great. Well we will move on to the next slide here, so ongoing monitoring.
Nathan: Yes. So, this slide basically summarises the entire thing, right? So the first column covers what we have already discussed and then we follow on with what we need to do. And it is really quite straight forward. So the first thing is, we need to see them at 30 days and the main reason that is there is that we need to confirm they are HIV negative. Okay? Because that is one of the main risks that a person has HIV, is in that window period, they continue taking PrEP which is not a full treatment and they develop resistance. In practice it has not turned out to be a major issue but it is a bit of a risk and we just want to make sure that is not the case. So we assess whether they have got any symptoms of infection and we do another HIV test. But we take that opportunity to do the adherence counselling as well, because at 30 days they have been taking it for a while, they know what sort of side effects they are getting, they know how they are going with adherence and it is a really good opportunity to talk to them about it.
So we discuss the risks. In terms of just annoying side effects. So the majority of people get some degree of tummy upset nausea. It generally settles down by about the 30 day visit and whatever they have got at 30 days is probably what they are going to continue with. So if they do have nausea, so firstly talking about making sure they are having it with plenty of food, experimenting with different times of times of the day can help. But ultimately it might just be weighing up that nausea against the benefit they are getting and different people have different perceptions of that. They can always fall back to condoms of course. So after the 30 days, so they have still got the same script, you have not needed to write a new script at this point, but by 90 days the script has run out and it is actually designed that way because we want to see them every 90 days. So at 90 days we do a full STI test including HIV test, so that just gets done every 90 days. Obviously we do the side effects and adherence and that sort of thing, and we do the renal function. So basically we need an eGFR at 90 days and then every second 90 days we do that again. Okay, so we do not necessarily need to do that every single time we see them. To be honest I think some people just do it every time because they just make a test set with the eGFR in it, but yes technically they do not need to necessarily do it every single time.
In terms of doing a urine albumin creatinine ratio and a protein creatinine ratio, because the actual effect is not where albumin comes from, it is actually on the tubule web where protein come from, so you really should order both of those. So you generally only need that if either you have got a declining eGFR and you are a bit concerned about it, or they have got some other reason why you are worried about their kidney. So in that scenario, I would be doing the urine ACR and PCR every 180 days at the same time as you do the eGFR or more often if they were on something nephrotoxic.
Brad: So just if you need that further information.
Nathan: Yes, exactly. Yes. So that is where discretion comes in a little bit, but you know, the baseline is every six months, but if someone has got multiple issues so you know, renal issues, in which case they are probably getting it done every 12 months already, then you might want to increase the frequency.
Brad: Yes, okay. Well we will move on here. So we are talking really about the population that we are focussing on at the moment. So you can lead us through what is happening with other STIs in New South Wales at the moment, Nathan?
Nathan: Yes, look I mean it is really interesting and this has certainly been something that globally was of concern when PrEP started to be rolled out, that what we would see is an explosion in STIs because people would stop using condoms. So the slide you have got up there is data from EPIC. So EPIC was a really large open label study in New South Wales where people were enrolled and put on PrEP and then followed over time. So it was not a randomised trial or clinical trial in that sense, but it was about 8,000 people in total that were closely followed up, so we had all their test results and things and we could see what happened. And so what we found was there was very high rates of STIs at baseline, so greater than 20% or one in five had an infection at baseline. So I am really showing that we highlight that this group were already highly sexually active and having unprotected sex already. Then we followed over time and we really did not see an increase in that positivity rate. So interestingly, if you look at other data, there has been a shift, so there is a reduction in condom use it appears overall in gay men in New South Wales, but it seems that it has been offset by the fact that we have now got a whole bunch of high risk gay men seeing clinics every three months, getting tested, getting treated, telling their partners. So it seems when you balance those two things out, we are not really seeing any negative impacts on the STI positivity rate. That said you know, we do still encourage condom use. So we are not selling PrEP as like this is a solution to everything and throw away your condoms. We are talking to people on an individual basis about you know when they might chose to use condoms, what works for them. And some people obviously chose to continue to use condoms and not use PrEP, and validating that choice.
Brad: Yes, and if you have got more people in a routine and coming in every three months to get checked, then you are hopefully treating things earlier so they have less time to spread.
So we will go onto the next slide here. So this is a case study. We are going back to Mo. So, Mo returns back to your practice for his repeat PrEP prescription. So he has been taking PrEP every day for three months now. He has had some hook-ups since the last visit and he has had condomless anal sex with two new male partners. So, you are organising HIV and syphilis serology and you are doing the kidney function, the eGFR and plus you are testing for chlamydia and gonorrhoea as well at this time. So, what happens? Mo’s test results come back and he is positive for rectal gonorrhoea. So, we sort of like want to know that we are giving the right treatment for gonorrhoea at this time, and I might just do a poll before we go any further, to ask everybody what their opinions are. So, I will go to there. So the poll is open. So yes, so what is your first line treatment for gonorrhoea in Australia? So, is it the first one, so Cefixime 400 mg orally as a single dose? Is it Ceftriaxone 500 mg for an injection? Azithromycin 1 gram orally as a single dose? Or Ceftriaxone 500 mg and Azithromycin 1 gram by mouth as well? So, yes, so 67% I think on my small screen here is for the last one, so for the Ceftriaxone injection and the Azithromycin 1 gram by mouth. So yes, so most people are choosing that one, possibly because I put it up on the screen accidentally earlier on if you caught that. But yes, this is one of the things that often will change as time goes on and I will just go to the next slide here. So yes, I suppose just summarising this, we are just finding that gonorrhoea is becoming more and more resistant as time goes on. It used to be other treatments, it used to be tablets. Now it has moved to intramuscular injections and tablets. It is probably going to change again in the next sort of six to twelve months. We will see what happens. And yes, we also want to consider doing a culture. So, with Mo, if he is coming back with a positive gonorrhoea result of the rectum, sometimes we do consider doing a swab, sending it off and getting a micro-culture and sensitivity. Nathan, do you advise doing that with every case or just every now and again? What is your practice?
Nathan: Yes, look at the moment in Australia the guidelines recommend that you do it with every case and so if someone is coming back and they have got a known positive and you are treating them, you just quickly send off the swab for that. We only get about 25% culture rate, so we want to sort of maintain that level.
Brad: Yes. So and one of the guides is up there on the top right, so if you were just Googling Australian STI management guidelines that comes up with all of the latest recommendations for treatment. And every now and again I will just go to the website and make sure that I am giving the right treatment because yes, it does change from time to time. So the Electronic Therapeutic Guidelines is all good as well. Some people have access to that, some people do not. But yes, either are good references. The STI Management Guidelines is one of the free ones so that is fun and yes, cost effective.
So, we will move on to the next poll here as well. So, partner management. How far back do you contact and trace partners? So yes, looking back how many people do you contact, how many people do you ring, how many people do you test? So the results here. So we have got some people saying two months, some people saying 12 months, going back through the partners. What do you reckon, Nathan?
Nathan: Yes, so the Australian guidelines recommend two months for gonorrhoea. So six months for chlamydia, two months for gonorrhoea because gonorrhoea tends to resolve or become asymptomatic much faster than chlamydia.
Brad: Right, yes. So we will move on quickly through here. So, that is just some slides there. So again, like rectal gonorrhoea is largely asymptomatic so often people have it, they do not know about it, so yes, you do not know when those symptoms really started. But hopefully your patients are in a routine of having things checked every few months anyway.
So, this is just a note. So, if you are wanting to tell your partner that you may have been diagnosed with gonorrhoea recently, then you can go online and send an anonymous text message. It is always more polite to give somebody a phone call or a text yourself or through your dating App, whatever it is direct contacting it great. But if there are issues please make sure that your patients are aware, so either the DramaDownUnder.info so that is one of the sites. And there is another one that is called LetThemKnow.org.au as well. So the DramaDownUnder is a little bit more targeted towards gay and bisexual men. LetThemKnow.org.au is a little bit more targeted towards the heterosexual population but either is fine. So, please note that you cannot send a text to somebody saying that they might have been exposed to HIV. That probably deserves a phone call in my opinion. So, yes, so Mo should return for a test of cure at about two after treatment, after having the medication. Why is that the case, Nathan?
Nathan: Yes, so rectal infection is more difficult to treat than other infections and we know with gonorrhoea that there have been cases of resistance and so what we want to do is check at two weeks to make sure it has resolved. If it has not resolved at that point, it does not necessarily mean it is failed treatment but it is where we would then look into well, were their partners treated? Did they complete their course of treatment? We look at the culture result and assess what to do next.
Brad: Okay, no worries. So, we will go through a few slides here. So, yes this is just a reminder that if your patient does not have finances or does not have Medicare, that you can still refer to your publically funded sexual health service. So you should know the one that is in your area. If you do not, then please ask somebody around or you can also call the Sexual Health Info Link number as well if you are needing some phone advice for any of the things that we are talking about today too. If you are needing urgent advice, nine to five, are people calling you as well Nathan? Are you the guide around the Hunter Valley area?
Nathan: For contact tracing?
Brad: For contract tracing and for sexual health?
Nathan: Yes, yes. Yes. So we take a lot of calls. And so yes if you ring up the Sexual Health Info Link and you need some local stuff they will put you through or you can call us directly. Most of the clinics now have a web page and you can get the number. Almost all of the clinics have a nurse rostered on to answer the calls and if it is in any way complicated or you just want to speak to a doctor they put you straight through to a doctor.
Brad: No worries. So we will come back to Mo here. So back to the beginning. What if Mo’s baseline HIV test came back as positive? So we are looking at the step 2 of the prescribing pathway and yes, you know it is a realistic possibility that if we are testing people that are in a high risk group, that it may come back as HIV positive. So it is often difficult to present that news to people. We will go through that in a few minutes.
So we will sort of start with the HIV landscape at the moment here. So these are some of the figures from New South Wales. I think there has been a new update recently so these might have changed, yes just in the last few days. But last year there were about 313 new HIV diagnoses in New South Wales and 34% of these were diagnosed in general practice. So this is one of the things that I am wanting everyone to know, is that yes, a third of cases are really being diagnosed by people who are not working in HIV and so you have got to be aware of it. And sometimes people do start to present with symptoms and this is what we are finding in the heterosexual population, is that they are not thinking about HIV. GPs are not thinking about HIV. Nobody is thinking about HIV and sometimes they will feel tired or they will start to get odd infections. So it is always yes, prudent to keep that in the front of your mind and it does not really take much to do an HIV test. But yes, you have got to be thinking about it first. So we are seeing a significant decrease in gay men or men who have sex with men. We are finding that the new HIV diagnoses are going down over time and this is from the strategic response, not just PrEP but everything else that we are doing. But we are not making much of a change in the heterosexual population. And also we are finding that there is a bit of a blip on the radar for overseas born men who have sex with men as well. We are not reaching that population. And certainly yes, if you do have a gay or bisexual man who is born overseas they might be here studying, certainly think about HIV being on your radar and think about PrEP.
Nathan did you have any comments about that at the moment?
Nathan: Yes, no, I just totally agree with you. So many men are on PrEP now but obviously the majority of them were engaged in the gay community seeing clinics like mine or GP practices like yours, Brad and you know reaching the rest of the population that really we are seeing the HIV increases in means we need to get PrEP being prescribed more broadly out there in general practice.
Brad: Yes. So we will run through a few things here. So, just talking about HIV in general. So this is a slide to remind people what it was like in the 1990s. Often people were on up to 38 pills a day. I have had a few patients talking about that regimen. They needed to time their watch. They needed to take it at specific times of the day to make sure that the drug was in their system long enough. But today a lot of people are prescribed just one tablet a day and it is delivering multiple drugs and lasts for a long time in their system. So it is getting a lot easier as time goes on. This is what we mentioned before. U=U. And this is a really important message so I will repeat it. But yes if somebody has an undetectable viral load in their blood stream, then they are un-transmittable. So they are unlikely, extremely unlikely to be able to pass it on to their sexual partners. So I am just really getting that message out there.
And so HIV is now managed as a really treatable chronic disease. We talk in HIV medicine about HIV being very similar to diabetes or osteoporosis, sort of something that we can manage in the longer term. People will often need to be on medication to help it be managed, to keep the virus under control but yes they can live very normal, long, healthy lives. And it is really important to tell our patients that, particularly if they are being newly diagnosed with HIV as well.
So Nathan, we are talking about getting an unexpected HIV diagnosis.
Nathan: Yes. So, we know that GPs are diagnosing a greater and greater proportion and so because of that New South Wales Health has set up this system called the HIV Support Program and in each area there will be either an HIV specialist or a sexual health specialist that is the coordinator. And basically their role is to help the GP deal with it in the first instance and to make that sort of link to ongoing care if it is required. So essentially what happens is that when the test comes through the lab will obviously notify us because it is notifiable, and then New South Wales will ask if you want assistance with it. And if you say yes and then that is passed on in a de-identified way to the local person and they will call you up and provide you with essentially whatever support you need. But there is a bit of a structure that I think we are going to go through. And I guess the feedback that we have got has been really positive.
Brad: We will go through the things to be thinking about when you are giving an HIV diagnosis. Would you like to run through those, Nathan?
Nathan: Yes, and look to honest a lot of it when I make the calls. You know it is quite individual and it depends on both the doctor and the patient’s situation exactly and the details. But a lot of it really is you know encouraging the GP that they actually they can do this, that the skills they have already got is really the main thing they need. So GPs are giving bad news all the time and it is the same rules that apply in this situation that would for any other significant piece of bad news that you are giving to people. So the key step is really that before you give the result that you are prepared. So that you know what you are going to say. You have got the patient in. You have got time, so that might mean a longer appointment if you can. Certainly making sure that you have sat them down and they are ready to get the news. Sometimes if you think it is appropriate they might want to bring in a support person because we all know that people do not take in all the information when they are shocked. But essentially the piece of information to give at that first moment, is that obviously that they are HIV infected, but that does not mean a death sentence today. That HIV is a treated chronic infection and that with appropriate management they would expect to live a normal life span and they do not really pose a risk of transmitting to others because we know U=U.
Brad: Yes. It is one of these flips that happens with HIV. We sort of say, do not get it, do not get it, it is terrible, make sure that you are taking PrEP, make sure that you are protecting yourself. And then if somebody does get a positive diagnosis then we also have to go, okay well it is not that bad we have some great treatments and there is that flip in our language that we use as doctors.
Nathan: Yes that is right. And so we generally, we will arrange that specialist appointment straight away, and most clinics will prioritise that and get them in very, very quickly. And the majority of people start treatment extremely quickly now. And so that is part of the role of that HIV Support Program, is really just to facilitate that and make it easy. But of course once you have done that, you have given them the news, you have explained that no it is treatable and this is what I am going to do to get you on treatment very, very soon, we do have some things that we have just got to make sure we cover early on. So if you flip to the next slide, Brad.
So we do need to think about the public health implications of this. So we do have a new diagnosis of an infectious disease. So we need to make sure quite early on that the patient knows that they need to take reasonable caution to prevent transmission to others. And so essentially, you know at the point of diagnosis that is going to mean using a condom or not having anal or vaginal sex. But then going toward reassuring them that that will not always necessarily always be the case and once they are undetectable that they will not necessarily need to use a condom. So that is about ongoing risk. But we also need to think about people who might have been exposed, particularly recent partners. So we covered contact tracing in the context of gonorrhoea so it is even more important with HIV. So with contact tracing at this first diagnosis, I do not generally recommend that you start getting a list of all the people they need to notify and start notifying them. It is just not the moment for that. That may well be something that you might help them do, or it may be something that the referral service does. Either way, it can be done later. What we do need to know though, is do they have a partner at home that might be at risk and might need PEP. So if there is a person that has been exposed in the last 72 hours and they are prescribed treatment with PEP – post exposure prophylaxis as we would for needle stick injury – then that is something that we need to ascertain quite early on and facilitate that through your local sexual health clinic if needed, or Emergency.
Brad: Yes. And we are talking about, yes linking people in to HIV care. Just to summarise this, there is certainly the local sexual health clinics. So this is referring everybody to Nathan or your local clinic, HIV outpatient services, there are those around in different public hospitals around. There are yes, sexual health clinics if somebody does not have Medicare as well. And yes, there are people like me who are community HIV S100 GP prescribers. So we are hopefully becoming more popular and hopefully some people listening today will be very inspired to do the S100 course and get out there.
The other thing to mention here is just psychological care. So often you will not know who are the best people to talk to, or for your patient to talk to if they have just had a diagnosis. So it is an easy access for me or Nathan to get people on board and to direct into the right services over time. And yes, just making sure that people do not feel isolated. Making sure the GPs like yourselves do not feel isolated, but also the patient. Making sure there is enough support going on.
So, we will be running out of time to do the role play unfortunately, Nathan. I am sure you are disappointed with that. But basically the point of the role play is to remind you that yes, it is okay to call up the information line and yes, alright to have those questions. There is support available. Yes if you have not heard about it before that is okay. You may not have been in that situation. But certainly make sure that your colleagues at your clinics know that there is support and if they do have an HIV positive diagnosis come back, that they can get on line, they can call the number and just get their preparation organised before somebody comes in for their results.
Nathan: If I can cut in just briefly, Brad. So, one thing I guess we could not do is show the resources here but on the HIV Support Program website that New South Wales has, so if you Google HIV Support Program, there are a lot of like checklists for doctors that are really useful. But there are also really great leaflets that you can give the patient that has all the resources that they might need including help groups and that sort of stuff. So if you print that out you can give it to them at the time.
Brad: Yes. And there are some very industrious GPs around the country, around New South Wales who are creating their own information resources on their own local health network. So yes, I have seen some amazing information pamphlets that are on line for your particular area. So make sure you are checking out your local primary network as well. So yes, we should conclude this as we are getting just up to 8.30 now. So yes, just a reminder that everybody that is listening, that you are all playing a critical role in preventing HIV. Make sure that you are open to having these conversations about sexual health, that you are able to identify patients who might be at risk of HIV or other sexually transmitted infections. Keep asking your patients questions. There are the clinical tools that we have talked about today and we will also have on our last slide as well, a link to a lot of different sites that you can go to for further information. This is a listing of many of the sites. We will be sending a copy of the slides I think with an email afterwards. Samantha is nodding her head at me.
Brad: So, any final words, Nathan?
Nathan: I guess in terms of the you know, getting back to PrEP, the main thing about it is really just to be positive and encouraging about it. It is really pretty simple and with the skills you have already got and following along that flow chart, you really cannot go wrong, and your patients will thank you for it.
Brad: Yes. And so if you have got any questions feel free to send us a message, call us or call your local sexual health clinic. But, yes, so we will be trying to answer your questions that have come through as well. If we have not had time to address yours, we will try to go through those as well and feed that back to you. But thank you everybody for listening tonight. Thank you for your attention and I hope you are having easier conversations and are able to prescribe PrEP for your patients.
Sammi: That is great. Thanks Brad and Nathan again for joining us this evening. And to everybody on line, we really hope you have enjoyed the session and we will let you get back to your evening so enjoy the rest of your night.