Prescribing Pre-Exposure Prophylaxis for HIV in General Practice - part 2

Sammi: Good evening everybody and welcome to this evening’s Prescribing Pre-exposure prophylaxis for HIV in general practice part 2. Tonight we will be focussing on conducting a sexual history. My name is Samantha and I am your host for this evening. Before we make a start, 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.

I would like to introduce our presenters for this evening. We are joined by Dr Brad McKay and Dr Nathan Ryder. Brad is a General Practitioner at East Sydney Doctors in Darlinghurst. He is an HIV S100 prescriber and host of the Embarrassing Bodies Down Under TV show, TV presenter and medical advisor for the Today Show and Today Extra on Channel Nine, and host of HIV in podcast. 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 at the Hunter New England Local Health District, the HIV Support Program Coordinator at the Hunter New England LHD also, and Conjoint Senior Lecturer at the Kirby Institute, UNW and the University of New Castle. So, thank you Brad and Nathan for joining us tonight.

Brad: Thanks Sammi.

Sammi: No worries. And I will hand over to Brad now to take us through our learning outcomes for this evening.

Brad: Hi guys, it is Dr Brad McKay here, or just Brad, that is fine. But yes, thank you so much for joining us on this lovely freezing cold night around New South Wales. It is good to have everybody here listening in and learning about preventing HIV. So tonight our learning outcomes are all up on the screen. So by the end of this activity, you should be able to identify patients who are at high risk or at medium risk of HIV infection. You should be able to prescribe PrEP to appropriate patients and we will got through the step by step process with that. You should be able to complete a sexual health history and risk assessment, and that is really what we are going to be focussing on a lot tonight, looking at sexual health and how to word our questions appropriately, and also obtaining a formal consent for HIV testing and appropriately communicating these results to a patient. So yes, what happens if you get an HIV positive result. And then, using appropriate techniques to engage patients at risk of contracting or passing on an STI, sexually transmitted infection. So, this is just a reminder, like why PrEP, why are we doing this? We have a New South Wales HIV strategy that we are following and this is really under the umbrella of the United Nations and looking at a worldwide global strategy to prevent HIV around the world. So there is, what we are trying to do, is by 2020, is to virtually eliminate HIV transmission. So we are on our way towards that but we are not quite there yet, and one of the ways of preventing HIV is by using PrEP. This has been a really key role and this has really started to reduce the number of HIV infections that we are seeing around Australia at the moment. So yes, so it is just PrEP is vital for what we are doing and to work effectively we need all of you guys as well. We are needing PrEP to be available to the population, to the public who need it and we are trying to decrease those hurdles. So, it is all you guys job to help everybody out and to reduce HIV around Australia. So we will get the evening’s festivities started by putting a question up to you guys. We have got a poll here. So, this will be easy for some people who were at the last webinar. For the newbies this may be a little bit difficult because we are throwing you in the deep end, but yes, what are the correct medications prescribed for PrEP? Please select I think it is like A, B and C, so the letter / number. Letter A is it tenofovir disoproxil fumarate and Emtricitabine tablet 300 mg/200 mg once a day? Is it tenofovir disoproxil fumarate 300 mg and Emtricitabine 200 mg and efavirenz 600 mg once a day? And C, is it tenofovir DF 300 mg plus Emtricitabine 200 mg plus Rilpivirine 25 mg once a day? So, we have 41% of people have put their money down on A. So tenofovir disoproxil fumarate and Emtricitabine 300 mg/200 mg tablet, and that is the correct result. We have got 33% of people on B and 26% of people on C. So we are, I knew it was throwing everybody in the deep end, but yes we are talking about two drugs, so that was the first answer there, so A, using tenofovir disoproxil fumarate and Emtricitabine. It is one tablet a day and the script that we will go through as the webinar goes, is for 30 tablets and two repeats. So for a three month prescription. It is really important that you all know that you are able to prescribe PrEP. This has been a change from April 1^st this year. There are many other HIV medications that you need to do an S100 course for and I encourage everyone to do that, but from today you can prescribe PrEP for all of your patients. So if they are coming in asking you, you have that permission. So most of the time, the authority just pops up on the computer. I am used to it being automatic. If you are writing a manual script then the streamline authority number is 7580, but you probably do not need to remember that. And yes, if you are trying to find it on your computer, this is a screen just to sort of show you what you are looking at. On the left side of your screen, you can see that if you are looking up tenofovir, I know it is spelt very, very strangely, but that is it, it is the 300 mg / 200 mg tablet. It is 30 and then two repeats. So, if you are looking at that, that is what you are after. Some people who have HIV are on the same drug and they are using, if people are writing prescriptions for that, we have usually got the five repeats on it, so you do not want to click those, you are wanting to go to the 30 tablets and two repeats. And sometimes this is really complicated as well, so my cheat sheet way of doing it is by typing in Truvada, so T, R, U, V and then it will pop up and it has only got like a couple of options that you can use, and again it is looking for the one with 30 tablets and two repeats on it as well.

So, cool, so we will just go to the next screen here and this will, I think this will be sent to you as a PDF at the end of the webinar, so everybody should be able to get this. You can get this from the ASHM website as well, and this is known as the PrEP prescribing pathway, because we love alliteration. So this tool has been made by ASHM to make prescribing as easy as possible even though it looks very complicated. We will go through it step by step. So there is five, on the left side of your screen there are five steps that we will be following today. So, the first step that is there is to see if your patient is behaviourally eligible for having PrEP. If they are high or medium risk of getting HIV infection, it is also like number two is to see if they are clinically appropriate or clinically eligible for PrEP, so see if it safe for them to take it. Step three is which other tests you should be performing. So which tests you need before starting PrEP and also, seizing the opportunity to screen for other STIs. That is really, really important. So we will be going through that today, too. Step four is how to prescribe the PrEP prescription and then the final step is ongoing monitoring, so what do we need to follow up with our patients, what do we need to tell them. So this is what we will be going through and yes, so what we are needing to know. So we will be going through those five steps and we will review the practicalities of prescribing PrEP. Nathan will be going through that in a minute, but we will also be getting into the nitty gritty details of taking a sexual health history and how to determine if a patient would benefit from taking PrEP in the first place. Now, I am sure that some of you will already be very well practised at taking a sexual health history, but many doctors out there still find it difficult to initiate that conversation with their patients about sex. So, for many of you, it may be a number of years since you have been on a dating App, or it might be so long from your dating life that dating Apps probably were not around when you were dating, but the language of courtship has changed dramatically over the years and we will be giving you some practical tips and talking about some appropriate language to use with your patients as well.

So, this is step one of the ASHM PrEP prescribing pathway and this is about behavioural eligibility, so assessing what the patient is getting up to, and whether they will benefit from being on PrEP. So I will hand the next few slides over to Nathan and he will be reviewing what is necessary when we are taking a sexual health history and you will also be remembering that assessing for the risk of HIV and other STIs is only part of the sexual health history. So before we go to that, we will, before we go to Nathan, I think we have got a poll, so I will hand over to Sammi to ask about this poll.

Sammi: Absolutely. So we have just launched that second poll for you there, so the question for this poll is, which clinical consultations are appropriate for you to ask a patient about their sexual history?

Brad: Cool, so the majority, the vast majority of people have said all of the above, so 96%. The question was far too easy. So yes, it is certainly taking any opportunity to talk to our patients about it. But yes, so I will hand over to Nathan to start the next section of this.

Nathan: Okay, thanks Brad. So I think if we move on to the next slide. Yes, okay. So yes, the answer to the poll was really all of those situations would be a perfect time to take a sexual history. So clearly this whole webinar is around HIV risk, and that is what I guess the focus of what a lot of our discussion is going to be, but in clinical practice obviously taking a sexual history is going to come in handy in a lot more situations than just that. So we have got, you know, several things up there on the slide there. I guess many of you are probably already taking sexual histories in these situations. But I guess the one that often comes up for me when I do general education around sexual history taking is really the importance in chronic diseases and that often gets forgotten about, that most chronic diseases do have quite a big impact on people’s sexual lives and you know, making sure that you think about asking these questions in that sort of situation. And of course, we know a lot of our medications that we are prescribing will have an impact. So really, any of these situations would be an excellent time to ask your patients about sexual history and your patients will thank you for it.

Now if we go on to the next slide. So, we are just going to go through some reasons why we might take a sexual history and I mean, some of them are going to seem pretty self-evident, but I think it really helps to really unpack why we are doing it. So the first thing is obviously unless you really talk to your patients about these things then you are not really going to understand what is going on in terms of their sexual lives and sexual behaviour which is going to make it very hard for you to make appropriate recommendations and care for them properly. From a more practical stance, obviously the test that we might perform for the patient is going to very much depend on who they are having sex with and what sort of sex they are having. It is also going to help us provide some counselling around risk reduction, as we know risk reduction is not about a lecture, it is about understanding what is going on for that person and helping them come up with some strategies that they can put into practice that work for them. And finally, the test results are never black and white, or rarely black and white, and understanding what that test result is going to mean for that patient obviously relies on us having some understanding of their particular situation. And one thing that I guess comes up quite a lot is around informed consent or what used to be called counselling for HIV. So as I am sure hopefully people on line will know that we do not really talk about HIV counselling in relation to testing, but we do talk about informed consent as we do for any test. But you know, for any test you cannot really get true informed consent unless you understand their risk. And so taking a sexual history is I guess part of informed consent for all of the tests you might do, HIV and otherwise.

We go on to the next slide. So from the other side of it, taking a sexual history or I guess participating in the sexual history with you has a lot of benefits for the patient as well. So, talking to another person about what is going on in their lives sexually, what sort of behaviour they are undergoing and you know, what prevention means they are using can help them reflect on that and what they may want to change about it. Obviously, the process of discussing why you are asking these questions and what it means, is going to help them understand why you are recommending certain tests or certain treatments, and may help with them complying with that treatment. And lastly, it is really quite amazing how much asking about these sensitive things can help really build that engagement, so I guess that is a two way street, that is hard to ask the question before you have engaged properly with that patient, but equally if you make the effort to do it properly, it really helps build that relationship.

Brad: This is a very interesting question. So, what stops you from asking your patients about sex? So, is it A Lack of time, B Lack of practice taking a sexual history, is it C Embarrassment or shyness, or is it D Worried about your patient’s reaction from bringing up sex? So, we have as the results 33% of us are saying that it is a lack of time bringing it up. 21% are saying that it is a lack of practice taking a sexual history, so you have come to the right place because we are looking at that. 6%, very few of you are embarrassed, so that is a very good thing. 41% are worried about the patient’s reaction. So, yes a bit of a wide range of ideas there. So I will hand back to Nathan to continue on here.

Nathan: Okay, yes, it is amazing. I have seen those sorts of numbers come out in lots of different audiences and it is incredible how consistent it is that those barriers are really the ones that come out again and again, and there is a lot of research showing that those barriers are often brought up by GPS but a bit of practice can often get us past that. So, I guess before you even start there are a few things you can do to as the slide says, set yourself up for success. So these are things that are going to happen before you start asking the questions. So a really important one is just consider and reflect on your own cultural background, your own beliefs about sex. Obviously they are your personal beliefs and you are entitled to them, but you need to I guess reflect on how that might impact upon your body language and how you are going to deal with the consult and be able to manage that.

The next thing is, think about the environment. So, the physical environment, so how private is it or more importantly how private is the patient perceiving it to be, and secondly who else is in the room. So, if a partner is there or even a parent sometimes, that is going to make it a big difference to the information that you obtain and you might want to think about you know, separating people or moving to an appropriate location if required.

So before you launch into the questions, obviously you have to establish some level of rapport. I do not think that will come as any surprise for you when you are asking other sensitive information. But obviously it is really important with sexual health history. And you know, paying attention to the non-verbal cues, you know really picking up on if the patient is really super comfortable with this and it is okay to go, or is clearly not comfortable or if they are going to need a bit more Preparation.

And the last point I guess really is similar to the first one, that you really need to go in with an open mind and an accepting and non-judgmental attitude to what the patient is saying. You do not have to agree with them, but you do need to go in with a non-judgmental attitude if you want to get anywhere.

So if we move on to the next slide. So once we have got ourselves set up, you know we are comfortable that it is a private space and the patient feels comfortable, we really need to explain why we are asking the questions. And I really cannot stress this enough, I think this makes a massive difference to how well it goes, and if you start out on the wrong foot with something so personal as this, it is very hard to pull back. So the patient needs to understand why you are asking this. You cannot come out of the blue and ask someone a very personal question about their sex life, but if you start with, look I am going to ask some personal questions because it is going to be useful in helping me care for you, you might be more specific depending on what the context is I guess, the person is going to be much more receptive. Especially if you ask if that is okay with them, if they have got any concerns about that. And I always start with the easier questions. So obviously in my clinic people come in expecting to be asked these questions and even then it makes a big difference if we start with something relatively straightforward like are you sexually active or are you having sex with someone, versus launching into quite a detailed question about when was the last time you had unprotected anal sex which is obviously where we need to end up. So start with the easy questions and then work your way forward and you know, gauge the speed on their body language and their responses.

Brad: So it is like foreplay, Nathan.

Nathan: That is one way of putting it.

Brad: Just to put it into context, that is fine.

Nathan: So, moving on to the next slide. Alright, so this is a little mnemonic that I actually came across from the US Centre for Disease Control, but you see it in a number of resources and it is the Five P’s of sexual history taking. And I guess it provides a bit of structure to go through. So it is obviously best if you put it into your own language, but essentially what we want to know is whether the person is having sex with men, women or both. We want to know some sort of information about timing, the context of the partners, so are they casual or regular which is you know, a bit of a grey zone but I guess these days it can often come into whether they are meeting them online or on Apps, whether they are anonymous partners, whether it is someone they are in a relationship. So just having that sort of global context, then obviously moving onto the types of sex. I am not a big fan of this being a list, I think you contextualise it. So in a heterosexual couple, you know, there is a big difference between oral sex and vaginal sex in terms of pregnancy risk and STI transmission. I do not think it is that important most of the time to ask about anal sex in that situation, whereas with gay men it is very important as the risk of HIV is starkly different between oral and anal sex and the rate of condom use is also quite different. So I think contextualising that and not just asking incredible details all of the time.

A past history of STIs can be quite useful. Past STIs is one of the strongest predictors of future STIs. Obviously protection against STIs and prevention of pregnancy and whilst not on the five P’s, you sometimes see the six P’s, and the sixth P is performance or pleasure and that I guess comes into when you are taking a more general history around the impact of chronic disease and what not, asking somebody if they have got any issues with their performance or issues with enjoyment of their sex life. And I guess if you go through those six P’s then you have pretty much covered everything you need to do. So I think it is back to you, Brad.

Brad: No problems, so yes, so I think we are getting back to the PrEP preparation. So still on step one, behavioural eligibility. And yes, just in the middle column there, I have sort like written down I suppose it is some of the questions that I ask and how I phrase it. So just to give some examples, I usually sort of say, like if I am approaching a sexual history, are you having sex with men, women or both? That is my easy way of doing it. Often I am surprised by the answer, so it is always good to keep everything open. I usually sort of ask about sort of yes, sexual history, injecting practices in the ways that are written there. So are any of your sexual partners HIV positive? Most people are pretty happy to answer that question. They are not too shocked by it. Do you usually top or bottom? So, that is just if you are the top, the penis, or the bottom, the bottom. Pretty easy. A lot of my patients will be using those terms and a lot of men who have sex with med will be using those terms, so feel free to use that as a question when you are out there. Do you usually use condoms? That is sort of like a general way, because most people are sort of very embarrassed if they are not using condoms all of the time because they want to impress you. And then yes, if you are saying do you usually use condoms, are there times when you do not use condoms, often patients will say, “Yes I use condoms 80% of the time, but 20% of the time I do not”. Do you have access to safe injecting equipment? That is a very formal question, so yes, wording it however you want to word it. And have you shared any injecting equipment, that refers to whether they are at risk of HIV, Hep B, Hep C and what we have got to be thinking about for them. So these answers will sort of guide the assessment of your patients and whether they will be appropriate for PrEP of not, and I think we are going to be going into a bit of a role play with myself and Nathan. So I will be the patient and Nathan will be the doctor, and we will sort of show you how the consultation will go. We will test Nathan’s question style as a doctor and see how he goes. So the scenario as we are starting off, I will be Jason a 32-year-old male and I am just presenting to Nathan’s practice to ask about PrEP. I have seen some ads about it online. So we will launch into our beautiful role playing exercise with Nathan here tonight.

Nathan: Okay we will give it a go. So, hi Jason how are you going? I am wondering what you are here for today?

Brad: Yes, not too bad, Doc. I have just, I have seen some ads about PrEP and I was just sort of like, yes, wondering if it is appropriate or if I should start it?

Nathan: Okay, yes sure we can discuss that. So before we get into the details though, I am going to need to talk to you a little bit about your level or risk for HIV and get a bit more of an understanding about your sex life. So do you mind if I ask you some personal questions in that regard?

Brad: Depends on how personal they are, but yes that sounds alright.

Nathan: Okay sure. Well look let us give it a go and if you are feeling uncomfortable just let me know. But all the questions I ask you, I assure you they are the same questions I ask all my patients in this situation and so we will just go through it. So, just to start with, are you having sexual intercourse at the moment?

Brad: Yes, I am active at the moment.

Nathan: Yes, okay, sure. So do you reckon you could just give me a bit more information about whether you are having sex with men, women or both, and in what sort of context you are meeting your partners?

Brad: Oh yes, just with men. Yes.

Nathan: Just with men?

Brad: Yes.

Nathan: Yes, okay, sure. Do you want to just tell me a little bit about the last time you had sex?

Brad: Oh well the last time was probably about eight weeks ago. So, yes, so I have just, I have got a friend that I catch up with every now and again. We sort of, um, met on Grindr and yes, just sort of meet up a couple of months when he is in town. Yes, so that was sort of like the last time, so he is sort of due to be in town again pretty soon, so I was just wondering you know, if I need to protect myself.

Nathan: Okay, sure. So when you meet up with him, what sort of sex do you generally have?

Brad: So I am usually bottom, so he is totes mass top. So yes, so he is, that is usually what I do.

Nathan: Okay, okay. And what sort of things would you do to protect yourself against infection?

Brad: Um, well the first time we sort of met up we like, I asked him to use a condom and then he says that he sort of HIV negative and yes, like I think he was on PrEP. I am not sure what is happening now. I think he mentioned it a while ago. But we do not use condoms anymore because I have met up with him a few times and yes, like he does not look like he has got HIV or anything, so yes I am not too worried about it.

Nathan: Okay, sure. And are there any other partners that you have had in say the last three months?

Brad: Um, yes, I have got another couple of guys that I meet up with, yes.

Nathan: Okay and is that sort of a similar type scenario?

Brad: Um, yes, so with them yes I think we started using condoms but then yes, like we were sort of used to having sex with each other so we do not use condoms any more.

Nathan: Okay, sure. So you have got a few partners that you know and you are pretty sure they are negative.

Brad: Yes.

Nathan: And you are a bottom and not using condoms, is that right?

Brad: Yes, yes.

Nathan: Yes, okay. And alright. So I am just going to ask you another few questions about your HIV risk, because other ways it can be transmitted is through particularly injecting drug use. So do you use any drugs at all?

Brad: No. I just have some dope every now and again, but yes, nothing heavy.

Nathan: So no injecting drugs. Do you use drugs during sex?

Brad: I have got a few friends that will sort of bring out a pipe every now and again, but yes I do not get into it. I am just not interested.

Nathan: Okay, sure. Have you ever had a test for a sexually transmitted infections or HIV before?

Brad: Yes I went to a sexual health service about three months ago, and yes they did some checks and everything was fine then.

Nathan: Okay sure, so about three months ago you were HIV negative, and?

Brad: Yes, yes.

Nathan: And had some other tests. Yes, okay, sure. Alright look, I think that is enough information to get an idea of your level of risk. I would love to tell you what I think, but I think I have got to put it to the audience, don’t I?

Brad: Sure. Yes. So we will take it to a poll for Jason. So based on Jason’s sexual practices do you think he is a high risk for HIV infection? So either A for yes or B for no. So the vast majority, so 94% of people are saying yes. We have 6% of people saying no. So, yes the, what are your thoughts, Nathan?

Nathan: Yes, so I mean I think the answer to this question is yes. I think Jason is at high risk. So he is having condomless anal sex with known male partners. He thinks they are HIV negative, but he does not really know. He is relying on what people have said and they are not in I guess a close relationship. So we would generally consider that to be an unknown HIV status. And I mean these people may genuinely believe that they are HIV negative, but that is a bit different to definitely being HIV negative. The other thing which I guess we went a little bit off topic, but so using amphetamines during sex is quite a strong risk factor for HIV and I guess that came out as well. He had a negative HIV test three months ago which is great, but he has not had a recent one so he would probably want to repeat that. But importantly his last sex was eight weeks ago. I am not sure if that came out, if we said that or not?

Brad: Yes.

Nathan: So, and that is going to come up really important because that means that Jason is at risk of contracting HIV in the future, but he is not at risk of a very recent transmission, so he is not really a candidate for post-exposure prophylaxis, more for pre-exposure prophylaxis.

Brad: So, yes, so do you have many patients who come in and just say yes all of my partners are negative, Nathan?

Nathan: Yes. I mean, I think it is becoming more and more common so a lot of people meet partners on line these days. It is quite common to use the settings on the sites and the Apps to communicate your status. I am in a regional area, so there is probably a little less sort of venue and anonymous sex that we see. Obviously it still exists, but it is certainly less than I saw in Sydney. So a lot of people do know their partners. I guess PrEP has also changed it a bit because quite a large number of people are on PrEP and hence will feel they know their status. And yes, so I think a lot of people do come in saying, look I know these people, you know I do not feel I am at risk. But if we flip that around, we know a lot of the new HIV cases you know, do fall into that group where they, they really felt that they were not at risk because they thought they knew their partners. It can be quite a false sense of security in some situations.

Brad: Yes, I always tell my patients that it is my job to play devil’s advocate and that even if they trust their partners, I do not. So I give them that permission to just presume that they could be at risk and yes, most patients are sort of receptive to that.

Nathan: Yes, yes. So, I think back to me. So yes, so we were just really talking there about the behaviour eligibility. So step one was assessing behaviour eligibility and we have established that our fake patient Jason is eligible from a behavioural sense, so he is in the high risk category. So the next step two, is moving on to clinical eligibility. So I think we have got another slide on that one?

Brad: Yes.

Nathan: Yes. So to assess clinical eligibility, we are going to need to do some testing. So really the main things that we need to know for clinical eligibility is their HIV status and their renal function. So the HIV status because if you already have HIV and you take PrEP which is a partial HIV treatment, you can potentially induce resistance and obviously it is not going to do any good. So we need to know that for certain. And the major risk factor of PrEP is that, it is very small but it is there, risk of renal impairment. And really the only situations in which there has been some significant problem has been in people who have pre-existing renal impairment. So we really need to identify that the person has normal renal function as in an eGFR greater than 60. So we need to do the test on the line. Hepatitis B, that is there as a baseline to make certain because you know, despite the fact that it is recommended across the board for any high risk gay men, there is a special reason for testing in PrEP and that is because as I am sure most of you know, tenofovir that is a component of PrEP is also a drug which is used in hepatitis B treatment. So if you have got someone with chronic hepatitis b, and we put them on PrEP and they stop and start which they may choose to do, they will be at risk of a flare of hepatitis B from stopping and starting treatment. So we really want to know their hep B status. It does not mean they cannot have PrEP but you would have to make sure they understood the risk of stopping it.

So, in terms of the HIV test, one important thing we need to know is the window period. So we need to know they are negative at the start and there is you know, a 6-12 week window period. The labs all recommend 12 weeks. That is the official window period. Clinically we are generally pretty happy with six. So we have really got to be mindful of that when we are thinking does this person have HIV or not? So we sort of touched on this before and we will go into a bit more detail now. So what happens if the history was a little bit different and Jason had come in saying he had receptive anal sex in the past 72 hours? And that is actually pretty common because if you think about it, people have to have some reason to come and see you and it often does relate to a concern they have got which is recent. So this will come up in real life not that infrequently. So if there has been exposure in 73 hours, you need to think about post-exposure prophylaxis.

So if we go on to the next slide. The post-exposure prophylaxis is taking the same drug, the same HIV drug but after an event to reduce your risk of contracting HIV. So probably most of you have heard it in relation to needle stick injuries. We know that it works quite well, probably 70% to 90% effective. The nPEP you will see in the title, that just means non-occupational PEP. That sort of separated occupational versus non-occupational, but essentially it is the same thing. Take Truvada the same drug within 72 hours of exposure and that will reduce your risk of HIV infection. You can get information on this, you know if you look at the flow chart you can see that there is a PEP hotline and you can ring up and get information. And there is also a sexual health info link line.

So if we go on to the next slide. So I think, yes that is the one. Yes, so it is exactly the same two medications between PEP and PrEP. It is just whether it is before or whether it is after. Really the reason why it is different and you need to get your head around it is because, if they have had exposure recently, you cannot just give them a script and say okay, go to the chemist and pick it up because they may not necessarily get that within 72 hours, particularly as they probably have not seen you for the next hour, they are probably going to be partway through the 72 already. So you need to make sure they can get it. So you need to facilitate that. PrEP is obviously continuous, whereas PEP, post-exposure is one tablet a day for 28 days. We always, because it is not 100% effective with PEP, we always make sure they get follow up testing afterwards and they usually recommend that at around 4-6 weeks when they finish the treatment and then 12 weeks is the definitive final one.

So if we go on to the next slide. Essentially if you are in this situation, so you have got a person coming in. You have assessed them for PrEP or they have requested PrEP but you work out that they have had a recent risk, then what we recommend is that you ring one of these two numbers on the screen, the PEP line or the info link line, and explain the situation and they will help you work out the best way to go. So, sometimes that might be referring to an Emergency Department or a sexual health clinic or an S100 prescribing GP or a GP that can prescribe HIV medications. Other times, particularly if you are need a pharmacy that stocks PrEP, you might be able to give them a PrEP script and start them immediately. I do that quite a lot because I know there is a pharmacy near me that has it in stock. But that is not going to apply everywhere and that is why you need to ring up and get some advice.

Brad: So if we just pick that apart a little bit further, Nathan. So if somebody is coming in and they have had unprotected sex in the last 72 hours, so they have been bottoming, then yes if you are wanting them to be on medications straight away, the drugs, are you saying that the drugs for PEP and PrEP are exactly the same, or not?

Nathan: Yes, they are exactly the same. There is no difference whatsoever. So they are interchangeable in that sense. They are different in the sense that from a PBS perspective, so PEP is not funded by PBS, whereas PrEP is. So, but I mean that is only really an issue for people have a one off event that are not at ongoing risk. So the majority of circumstances, both the script that you would write and the drug and everything is all the same. The critical difference is the urgency at which you need to put them on it.

Brad: Yes, so the vast majority of cases like this it would be the same medication. So the Truvada or tenofovir and emtricitabine is what we are talking about. In some situations, for people at very high risk then we will add in another drug for PEP as well, is that correct?

Nathan: Yes, yes that is true and that is another reason why we are saying to call the number, because they will be able to advise you whether that was required or not. So essentially if you ascertain a risk then you ring up and then you find out how to get access and whether you do need that third drug or not. So the third is definitely yes, different and you would not be able to get that through a PrEP script.

Brad: And yes the people that are on the end of the hotline having coffee with their friends and they always seem to be very happy to take your calls and just sort of ask all about the sexual practices while they are having a burger and chatting away. So it is a good discussion for them when they are on call. But yes, the other thing is, yes, just to reiterate that if you are getting people to be on PrEP then yes, well you have got a bit of time up your sleeve. You are wanting to do the HIV test and check their kidney function, and if that is all okay then yes, get them on to it. But if it is PEP, then yes, certainly call up the number and just ask where to go because you might need the patient to go to the Emergency Department rather than their local pharmacy because your local pharmacist might not have it available and yes you are not wanting them to sort of delay getting it if they are needing it early and waiting 24 hours for the pharmacist to order it in. So there is a tricky question. So what if Jason’s test comes back as HIV positive? Nathan?

Nathan: Yes, so that is actually on the flow chart and this sort of provides a bit of information on what to do there. But essentially obviously if the person comes back with an HIV positive result, then they are not a PrEP candidate and we need to manage them from an HIV perspective.

So if we go on to the next slide, it has got a bit of information there about a great program that we have in New South Wales called the HIV support program. Actually often when I talk about this a lot of people say, well why don’t we have this for other issues like a cancer diagnosis and that sort of thing? But I do not know, you need to talk to New South Wales Health about that one. But essentially what happens is, if you get positive HIV results and you are not known to be an HIV specialist doctor, then the lab will ask you if you want to be contacted by New South Wales Health. If you say yes, then the de-identified notification comes through to your local coordinator. So for Hunter New England it is me. Every area has its own coordinator who is a local doctor, and they will sort of call you up at a time you nominate and help you work out where to go with that. The key thing about it I guess is they have got the five support services there and I guess that is how we sort of conceptualise what the person needs. It really is an individual call between you and that specialist and working out what you need if you have diagnosed people with HIV before or if the person is really expecting it is going to be a totally different situation than if it is an unexpected diagnosis and it is the first one you have ever made. But sometimes it is you know, how do you give this unexpected result and immediate referral. Other times it is helping you do those early stages and getting it through to treatment sort of at an appropriate time. I think that is it for that one. Do you have anything else to say on that one, Brad?

Brad: Yes, I just remember when I was diagnosing my first patient with HIV many years ago, and I was just like shaking when I got the paper through and the lab calling me. So yes, it is really great if you are nervous about it and do not know what to do, just call the number and people are used to dealing with it, they know what they are doing, so yes, so it is good to have a management plan before the patient walks through the door, so you are shaking less and looking less nervous when you are trying to give them that piece of news.

Nathan: Yes, yes. And I guess one of the big reasons why we try and do that straight away is you know, that aspect of delivery of the bad news and making that as appropriate as we can. But the other thing of course is, if someone is HIV infected today, we want to get them on treatment as soon as we practically can. So you generally get offered virtually an immediate appointment at a specialist service.

So, step three is to think about other testing. So that is other testing beyond those basic, baseline mandatory tests and so there is a few tests that are not necessarily mandatory, but they are pretty much routine. So that is up on the slide there. So we want to test people for hepatitis C. So we have already tested them and vaccinated them if they need it for hepatitis B, but we also test for hepatitis C.

Brad: There is just a question through as well from listeners saying why do we need to test for hepatitis C although it is not known to be sexually transmitted?

Nathan: Yes, that is a great question, and I just walked into that.

Brad: Sorry!

Nathan: So, yes, yes, no it is good. So I saw that question come up, because you know, it is a really point. So basically yes, hepatitis C is not really thought to be sexually transmitted, however there are some studies showing that particularly very high risk for HIV gay men and people that, gay men with HIV, do have higher rates of hepatitis C, so it probably is sometimes sexually transmitted. It does seem to be quite strongly associated with injecting drug use in particular or other types of chemsex. So chemsex is where you are using stimulants and erectile dysfunction drugs during sex. So it does seem to be strongly associated with that, but because we have selected out a high risk group here for PrEP, it seems prudent to also test for hepatitis C. So it is particularly important at the moment because as I am sure you all know, hepatitis C is easily treated with an 8-12 week course of treatment. So it is really important to identify that and treat it early. Does that answer the question do you think?

Brad: I think so, yes.

Nathan: Alright, so yes, so at baseline we test for Hep C. We also do STI testing. So STI testing is chlamydia, gonorrhoea and syphilis, and remember that that is not just in uterine it depends on the sites, so we will also be doing anal and throat swabs for Jason. And if Jason, obviously Jason is – well I do not think we actually asked that, but I am assuming Jason is not female. So if Jason was female, we would definitely need to do a pregnancy test.

Brad: Yes. And one of the other questions that has come through is that if you do have the service at your clinic of doing like a finger prick test for HIV when you are seeing somebody for that initial PrEP prescription, the PrEP consult, is a finger prick point of contact test appropriate, or do you need to send the blood off to the lab?

Nathan: Another great question. We are getting really good questions tonight, aren’t we? So we prefer a test from the lab. So the problem with finger prick testing is it does not contain an antigen in it. The one that does, is the disadvantage is it does not perform very well. It has a slightly reduced sensitivity for very early infections, so you have a longer window period. So we would recommend testing in the lab. You could do a point of care test as well if the patient wanted, but we would recommend to also do a lab based test. However, that is not a sort of a hard sort of exclusion because we would recommend follow up testing anyway. So if the patient was flat out refusing to do it, then I would prescribe PrEP in that scenario. But I have never, you know I have started hundreds of people on PrEP and I have never once had that problem yet.

Brad: Cool. We will go on to the next slide. So, yes, so we are just covering all of these points. So we covered these steps here. So we will go on to reviewing what you will need to discuss with the patient and when you are ready to give them a prescription, what is involved with follow up and then, where do you go if you are needing further support or information. So Nathan, up for the next slide.

Nathan: Okay, so as you have already explained, Brad, so the name of the drug is on the screen. So it is tenofovir disoproxil fumarate with emtricitabine. They are all fixed dose single tablets and they come with a number of different brand names. It is all done as 30 tablets. It is two repeats and there is a streamline code which hopefully will pop up in your software, but it is 7580. There are different codes if it is for HIV treatment. Um, so it is recommended that people take it daily. There is some data around intermittent and non-daily PrEP only really in gay men, so if you are using it in another person, we would strongly recommend against intermittent PrEP or other non-daily regimen. In gay men, if they really want to take it in another way, then I would suggest ringing for some advice, because this is a rapidly changing area I guess with the evidence around it. The reason why people other than gay men cannot really take non-daily dosing is because the drug levels in the vagina are much, much lower than the rectal tissue and so you would really need to be taking it daily in that scenario. So, that is basically what you need to know for a prescription.

In terms of what you need to tell the patient, so if we move on to the next slide. So in terms of patient education, what the patient needs to know is that it is not going to work immediately that they fill the script. They have to take the tablets for a bit of time to build up their protective levels. So from the data, it looks like seven days is protective for anal sex, 20 days for vaginal sex. But the recommendation from ASHM, the guidelines, is that really everybody should wait 20 days if possible, but definitely for anal sex a minimum of seven days. If they decide to stop PrEP, and people do because their situation changes, we have been amazed at how quickly people’s situation can change. So you need to take it for 28 days after your last potential exposure to consider you protected. You need to warn the people about the potential side effects. The main side effect people notice is some nausea that really peaks around two weeks and generally resolves around four. Generally people take it with food and experimenting with different times of day can avoid that. And the longer term risk is around bone disease. You need to discuss the importance of using condoms because although PrEP is virtually 100% effective against HIV, not quite but almost, it does not provide any protection whatsoever against other STIs and so we really encourage people to think about using condoms. And talking to them about how they might make that decision. And the last thing is just a practical thing that you know, just to warn them that the pharmacy probably will not have it in stock and probably will need to order it in. Generally it has been coming in at about 24 to 48 hours in most pharmacies. So it is not a major panic.

If someone misses a pill, so it is similar to a lot of medications, daily medications, so if you miss it be more than 12 hours then you just skip that day. If you remember within 12 hours you take it. It is pretty forgiving. We know from the data that four tablets per week is protective so if you are missing the odd dose that is not a big drama. Although, I probably would use it as an opportunity to get them to reflect on their adherence and just try and maintain it as high as they can.

Brad: And that is if they are male and having anal sex. So if they are female, then it may not be as forgiving.

Nathan: Yes, yes, sorry Brad a really good point. So females definitely need to take it daily. And that is really one of the things that took a long time to work out why the female PrEP studies were not performing as well and that is when they worked out that the vaginal tissue did not have as much drug there and it is really important to take it every day.

Okay so if we go on to the next slide. This is just a table. It is from the decision making pathway that you have got and it shows you the follow up testing. So essentially, so you test for baseline then we want to do an HIV test and a review of side effects and what not at 30 days. But then the main thing is every 90 days they come in and they have an HIV test, you know a clinical review for any side effects or new medical contraindications, full STI screen and in females pregnancy testing, and then every sort of six to twelve months we are adding in the testing for kidney function and repeat hepatitis C tests. Now, just to complicate it a little bit, you know going on from what was asked before. Not everybody does that Hep C test religiously every 12 months if someone does not seem to be at particularly high risk. But what is on the screen there is certainly in the national guidelines. You know a PrEP user is by definition a high risk person and doing a 12 monthly Hep C test is probably worthwhile.

Brad: Especially if the liver function is terrible.

Nathan: Yes, of course, yes.

Brad: A good summary slide with that one. But yes, we will return to Jason. So Jason is coming back to you for a follow up visit. So he is here for a repeat PrEP prescription. He has been taking PrEP every day and he is religious with it, so that is all good, every day for three months and he has had some episodes of condomless anal sex since the last visit. So, we will go to a poll. So what tests would you offer Jason today? So, A is no additional tests are required at this time. B is testing for HIV, chlamydia, gonorrhoea, syphilis and the estimated glomerular filtration rate. C is hepatitis A and B serology. D is hepatitis C serology. So, most of you are experts with this. So 92% of people are saying B, for HIV, chlamydia, gonorrhoea, syphilis and the estimated glomerular filtration rate. So, yes, that is after the three months. And yes, looking at the ASHM guidelines it is pretty clear with the table that Nathan showed before, yes what is the rationale for doing these tests, Nathan?

Nathan: Yes. So the rationale for doing the tests in terms of the STI screening, is that people having unprotected anal sex meet the PrEP criteria are going to be an increased risk of sexually transmitted infection. So it is really important that we are testing regularly, and I guess that is one of the reasons why we are pretty comfortable that although you know, this is removing people’s risk of HIV and there has been some concern that that is going to lead to an explosion of unprotected sex and STIs. That has not eventuated and we think partly because people are getting tested and treated you know, regularly. So what we recommend is a full STI screen, so looking at Jason who is a gay man, so that involves testing for gonorrhoea and chlamydia from urine, an anal swab and a throat swab along with a blood test for syphilis that you can add on obviously with the HIV because it is not a serology. Hopefully we followed guidelines and we make sure that Jason was immune to hepatitis A and B before we started. There is actually a hepatitis A outbreak at the moment in Sydney and Melbourne so it is really important to make sure gay men have been vaccinated against hepatitis A. And hepatitis C, you do not need to do it at the three month mark. So you do it at baseline and then you do it every 12 months. EGFR we said it is every six months, but we do do one at the first three monthly visit when they have had drugs for the first time to make sure there was not an early impact. So we do that regularly. So someone on PrEP will be seeing us four times a year, and STI testing is recommended annually for all men with a male partner, but up to four times a year for all MSM, particularly MSM who are having unprotected anal sex, having more than 10 partners, having group sex or using drugs during sex or chemsex as we discussed before, or obviously HIV positive, not really relevant to PrEP but if you did have an HIV positive person we do recommend regular testing.

So I think the next slide shows just some getting to some sort of tips how to get that done. You know, particularly bearing in mind the first poll where lack of time is obviously real barrier in this regard in general practices. So most of this can be done as self-collected swabs. So self-collected anal swabs and self-collected vaginal and throat swabs have all been validated all perform as well as clinician collected. This little thing of how to do it. You can laminate it and have it in your draw or on the toilet wall, really quite clearly explains you know even without having to necessarily even be able to read it, how to do it. Alternatively of course, you can give them a form and send them to a pathology collection service. So it really should be doable within the context to get these tests done.

Brad: And decrease the embarrassment if patients are doing it themselves as well, so good to have the signs up on the wall so they know exactly what to do. So, this is yes, just a website for a reminder, so STI.guidelines.org.au if you have not gone to that website, please go to it and have a look. It is pretty easy to look at what the different STIs are and look at the latest management strategies in New South Wales. It is always up to date. So, yes, so that is one of the good sites to go to. The, we are also recommending if you are wanting to in the future, the next webinar that we are doing around PrEP is also managing positive results with HIV. So we will be doing that a little bit further and we will be also focussing on contact tracing and partner notification as well.

So, we will go on to the next slide at the moment. And this is what Nathan, you were talking about this before about the rates of STIs around New South Wales.

Nathan: Yes, this is data from the EPIC study which ran for about two years before the PBS listing of PrEP and we got really good data around what is happening with STIs. So although there was you know, quite high rates of STIs as you would expect in a high risk group, and possibly some slight increase in chlamydia, it strikes me how stable these rates are. So over that couple of year period, we did not really see any increase in STIs, but again the rates are high and it is really a group that should be getting tested every three months.

Brad: Yes. So, and lots of patients are just sort of going, “Oh my God I have never been tested so many times in my life. This is amazing, I am best friends with my GP.” So that is always helpful. So if you have got a patient who is taking PrEP but they are still at risk of STIs, what is your process, Nathan?

Nathan: Yes, look I mean it is really important because we do recommend people continue to use condoms. We are not sort of trying to send the message here that PrEP is the answer to everything. And so we do ask patients about their condom use every time they come in. We do talk to them about how they make those decisions and I think this sort of brief intervention framework is a great way to go about it. So there is a tool on the Ending HIV site, it has got the link there, steps you through it. But essentially it is the same brief intervention that you would be using for smoking and other things, so really you know, helping the patient identify if they feel that they are at risk and if there is anything they want to change. For me that often comes up when the patient comes in with repeated STIs and says look, I am a bit sick of this. Get him to identify well, what are the barriers to you using a condom for instance? And then helping them to come up with some strategies for change. And it has to be quite practical. There is no sense just lecturing someone and saying, you know you are stupid, you should be using a condom. It is really about helping them work out, well when do I, when don’t I? How might I do it? So a lot of common things people might do, is do you really use condoms with the sort of random partners that they do not know well. But they might have a couple of people they know well and they know are getting tested for STIs regularly, you know maybe they will not use condoms with those people. So it is about them making a risk assessment and deciding what they want to do.

Brad: Additional advice.

Nathan: So, there are a few other things that you need to think about. So we have really gone through, this is by far and away the most common scenarios, but there is a list of things up there where you probably want to get some advice. So most of them are not absolutely contraindications, but they are situations in where, where you might want to have some different monitoring or particularly if they are under 18 you might have issues with the PBS criteria. So that is where you might want to get some information so you can call up the sexual health info link or any of your local sexual health services will be happy to either provide advice or potentially take over care if it is required. One thing really important to think about is Medicare and eligibility. So people who do not have the Medicare card but are at high risk of HIV, we do not want these people to miss out, so that is a really good group to think about discussing with your local clinic about how to get access, because there is means of getting access through personal importation schemes.

Brad: Yes. And here is just a reminder. We are going to finish up in a couple of minutes, but yes this just a reminder of the clinical resources that are available to provide support for everybody, a one stop shop for PrEP resources with the website there, Ending HIV. And yes, some of your, if you are in different areas around New South Wales, some of your local health districts will have different websites and they should be all up to date with resources for your particular area as well. So, please check out those websites. And yes, this is just sort of going through what we have, what we have talked about. So just summarising that you guys are who we are all relying on, so we really, are really pleased that you are here with us tonight and that you are learning about PrEP because you will have patients coming in and we do not want any awkward conversations. So we want you to know what you are doing and know that you are giving PrEP to the right people. Yes, PrEP requires, or it is great to provide this with an opportunity to check for other sexually transmitted infections as well and make sure we are treating everybody appropriately. Taking a sexual health history, we have gone through all of that so hopefully you are all fully capable now. Yes, the clinical tools and resources and we will be sending some of that information to you as well after the webinar and, um yes, just really important to discuss a patient’s risk of other STIs. We do not want to be forgetting about chlamydia or gonorrhoea and syphilis if we are just focussing on HIV. So really, really important to check for all of those, too. And I think we have covered most of the learning outcomes. I think that we have, I hope that we have covered everything here. So yes, that is just a refresher with everything and yes, I really thank everybody for tuning in tonight and for learning how to prescribe PrEP appropriately and a big thanks to Nathan as well for his expertise in this area, too.

Sammi: That is great, thanks Brad and Nathan as well. And thanks everybody on line for joining and we hope you all enjoy the rest of your night.