Skip to main navigation Skip to main content

PrEPared to Prescribe – a forum to talk and learn about the experience of prescribing HIV PrEP

Bethany:
 
Good evening everyone and thank you for joining us for the HIV PrEP Forum. Before we get started, I would just like to acknowledge the traditional custodians of the lands on which we all meet and pay my respects to the Elders both past and present.
 
So I would now like to introduce you to our presenters for this evening’s session. Dr Vincent Cornelisse will be our facilitator tonight. Vincent is a staff specialist in sexual health medicine at Kirketon Road Centre, and a New South Wales Health Conjoint Senior Lecturer at The Kirby Institute, UNSW.
 
We also have Dr Catriona Ooi with us tonight. Treeni is a Director at Clinic 16 at North Shore Sexual Health Service, Northern Sydney Local Health District.
 
Dr Miriam Grotowski is a GP at Smith Street Practice in Tamworth. Miriam is also a Senior Lecturer in Medicine at the University of Newcastle Department of Rural Health.
 
We also have with us tonight, Paolo Polimeni and Fery Lo who are both PrEP consumers speaking to their experience of being prescribed PrEP.
 
So before I pass you on, I just wanted to note that this training has been developed in partnership with the ASHM and the New South Wales Ministry of Health, so now I will pass you over to Vincent who will take us through the learning objectives.
 
 
Vincent:
 
Thanks, Bethany. So as you can see on the screen here, it is hoped that by the end of this CPD activity, you can discuss recent updates for HIV pre-exposure prophylaxis including how to prescribe and also the broadening of suitability criteria that came in with the most recent updated guidelines which were designed to increase access to anyone who is at risk of HIV. The second objective is to develop confidence in PrEP prescribing or follow-up through the sharing of GP experience or patient experience, and specialist advice. Thirdly, to discuss methods to overcome perceived challenges or barriers to prescribing PrEP and finally to identify tools and resources available to support PrEP prescribing in New South Wales. And as Bethany alluded to, we will at the end give you a summary of all the tools that are available and those will be emailed to you as well.
 
So as you can see on the screen, here is a poll which we would love if you could try and quickly complete for us, just to really get an idea of where each of you are at in terms of PrEP prescribing. So firstly, just asking how confident do you feel in prescribing PrEP? And then the second question is, what are the main challenges you have experienced when prescribing PrEP? Have you completed the list, tick those boxes.
 
 
Bethany:
 
We will give you a few more moments.
 
 
Vincent:
 
Thanks, Beth. Can we share those findings?
 
 
Bethany:
 
Yes. I will just give them a few moments as we have got a few more people voting still.
 
 
Vincent:
 
We have a chat box on Zoom as well, which I am sure you are all very familiar with, because I am sure you are all experts on Zoom now. Feel free to type any questions or comments in that chat box, and we are going to try to keep an eye on that during tonight’s session. And as Bethany alluded to, we are really keen to try and keep this as interactive as possible. I am sure some of you are very experienced at prescribing PrEP. Some of you may be less experienced, so we are really keen to address any of the concerns or questions you might have tonight.
 
So here we go, the results. So some of you, about half of you are somewhat confident and the remainder are somewhat split between not confident and very confident. So we will make sure that we cover the PrEP basics tonight quickly as well to try and get everyone up to the same, on the same page basically around PrEP. And then, in terms of the main challenges, firstly one that rated fairly highly was that you do not know much about PrEP and we will certainly aim to address that tonight. So by the end of tonight you will know a lot about PrEP. And the second one that rated highly is that you do not prescribe PrEP often enough and we can talk about that as well. Because certainly, as I said with the broadening of the guidelines and the broadening of the eligibility criteria there is more opportunity to prescribe PrEP for patients who may be at risk of HIV.
 
Great, so we will move on to the next slide. There is just a small number of didactic slides that we are going to run through, again like I said this is to get everyone on the same page. So this is the New South Wales HIV data from 2008 to 2020. AS you can see, the overall, since about 2012, the overall HIV rate in New South Wales has declined from a high of 413 new cases in 2012 to a low of 206 cases in 2020. Of course we need to keep in mind that the 2020 drop from 2019 is likely to have been affected by COVID. There was a significant reduction in HIV testing during COVID because people found it difficult to access testing services. Most of that drop has been attributed to the introduction of PrEP, so it is important to recognise that PrEP has had a significant impact on reducing HIV transmission in the community.
 
Let us move to the next slide. This slide is quite famous. It was presented at an HIV conference a few years ago by a Professor Holt and it is affectionately known as the rainbow slide, and this is really looking at what HIV prevention strategies gay men are using. And this is from 2015 on the left through to 2020 on the right. And as you can see, the yellow area is people taking up PrEP as their main HIV prevention strategy. And that has really expanded quite significantly over those five years. And we have had a really impressive uptake of PrEP amongst gay men in Australia, particularly when compared to other settings internationally. That has been the result of really close collaboration between the gay male community and the community organisations, as well as the medical profession and public health.
 
Let us move on to the next slide. If we, again looking at new HIV infections a bit more closely in New South Wales, again we are seeing a reduction. It is quite a squiggly line, so it is a bit hard to see the trend, but there is definitely a reduction in HIV diagnoses, particularly the darker blue line is early HIV diagnoses as opposed to people who are diagnosed late. And of course, the reduction in early HIV diagnoses is much more likely to be a result of PrEP rather than the late diagnoses, because if someone has been living with HIV for several years, unfortunately we would not have been able to prevent that with the introduction of PrEP in recent times.
 
So next slide please. So just to go through some of the changes in PrEP prescribing. I guess, for those of you who are less familiar, to set the scene prior to these changes, when PrEP was first introduced in about I believe it was 2014, or it might have been 2013, time flies, it was really targeted at people who were at quite high risk of HIV infection. So these were men who have sex with men, obviously all of those who were HIV negative and particularly men who have sex with men who were diagnosed with syphilis or anal gonorrhoea or anal chlamydia, or men who have sex with men who use crystal methamphetamine and particularly use crystal methamphetamine in the context of sex and then often had sex without condoms. There were some other risk categories for example trans and gender diverse people who met those criteria and heterosexual people who were considered to be at high risk of HIV. That was a few years ago. As I said at the start of this talk, those criteria have been broadened out and now really anyone who is at some risk of HIV is eligible for PrEP and in addition to that, it is recognised that some people might find it uncomfortable or might be hesitant to disclose their HIV risk when they come in to a doctor’s surgery, so if anyone who comes into a doctor’s surgery and asks for PrEP, they should be assisted to access PrEP without needing to further disclose their risk. And again, this is aimed at reducing barriers to access. So really trying to make it as easy as possible for people to access PrEP. The other changes are that PrEP is now a PBS restricted benefit rather than a streamlined authority as it was at the start, and the other big change is that a new PrEP agent has come on so that is tenofovir alafenamide, or TAF, combined with emtricitabine or FTC, it is a slight change from what we have previously used which was tenofovir disoproxil fumarate or TDF and emtricitabine or FTC. I guess we can talk about this later if anyone is particularly interested, but I think for your purposes, for anyone who is less familiar with PrEP, the main agent that we use is TDF, FTC or previously known is brand name Truvada which is PBS listed. But TAF FTC is TGA approved now but not PBS listed. But we can talk about that later.
 
It has been highlighted in the guidelines that we must consider actively promoting PrEP in under-served communities. So these communities are currently not particularly accessing PrEP but we are seeing increased HIV diagnoses in these communities. So there are people from culturally and linguistically diverse backgrounds, Aboriginal people, people in rural and remote locations, non-gay identifying men who have sex with men, and this highlights the importance of taking a sensitive sexual history when seeing clients because not every man who has sex with men identifies as gay and may not readily disclose same sex practices to you. At risk heterosexuals. Young men who have sex with men and men who have sex with men who live in areas with low concentrations of gay-identified men. So these population groups really would benefit from more active promotion of PrEP, particularly by their GPs which is of course where you guys come in.
 
So let us go to the next slide. And here we go, we are now going to talk about patient experiences. So I think Paolo it is over to you first.
 
 
Paolo:
 
I will just introduce myself if that is okay.
 
 
Vincent:
 
Yes if you could, thank you.
 
 
Paolo:
 
Hi my name is Paolo and I am a 48 years old gay man. I grew up in Italy. I have been in Australia for about 20 years now and have been doing some health promotion work with men who have sex with men.
 
 
Vincent:
 
Thank you, Paolo.
 
 
Paolo:
 
If you want me to start, I think you want to ask me something about my experience accessing sexual health and care.
 
 
Vincent:
 
Yes.
 
 
Paolo:
 
Very well, I will start with that. So, look in terms of my experience with sexual health care back in Italy, it is quite different from what we have here and what it is like today. So first of all, I cannot recall any sort of education or campaigns or anything coming up back in Italy in terms of sexual health at all. If anything, I remember a strong campaign against the use of condoms so pretty much kind of the opposite of what it should have been. There was a big influence from the Catholic Church and in our school we were told even by our teachers, we were told that using a condom is a sin and you should not use condoms pretty much. In that environment, I remember members of parliament, prime ministers, saying that gay men are paedophiles so they should not be allowed to work with children, these sorts of things. So that is the environment I grew up in. I am talking about 20 years ago, so I hope things are much better now. One thing I recall is when I was in high school in my last year, a very courageous editor of a famous comic in those days decided to initiate this just sort of one-off campaign by telling young people how to protect each other by using condoms considering that HIV was prevalent in people in their twenties in those days. And so, they could not print this as they normally do, and have it at the newsagency so they printed this strip and organised a massive number of volunteers going to high schools in one day to distribute this strip. It was a very cute family strip, a good sexual health promotion message. The education centre sent an army of police to the area of the high school to confiscate this strip and I was not even lucky enough to even see it. So this is the sort of sexual health campaign and messages I was getting in those days, so quite different. And in terms of testing, it was not a very easy experience, I was about 30 years old. I could not see my family doctor because I was afraid of my doctor possibly telling my parents that I was gay and I was not allowed to let my family know, I was afraid of my father who would probably have kicked me out of my home, and I was afraid of losing my job, maybe friends, and it was a very sad scenario. So one day I was travelling to Rome and I decided to be brave and went to the hospital and get this HIV test done, and it was a very, very difficult sort of situation at that point. So I was talking to this doctor about disclosing my sexuality which was not an easy thing to do in those days for me. I had been called homosexual by the doctor and I had to define myself as homosexual to get that test, which was a word I did not like, but I had to use it on myself to be able to get the test. There was very detailed terminology that was quite uncomfortable for me, and the doctor since I disclosed my sexuality did not look at my any more for the entire conversation. He was looking at the floor. So that was my first and last HIV test in Italy. I was lucky I did not catch HIV in Italy because I was far away from any sort of education and information at that point and I must say the fear of that sort of behaviour and sort of stigma kept me away from the services from that moment on. So, I guess you know, that is a very different experience from what anyone will experience today in Australia, but I guess it is kind of good to have an idea of what people have in their minds when they come and talk to their doctors sometimes, especially if they have come from overseas and they may have experienced something similar in their own country.
 
 
Vincent:
 
Thank you very much, Paolo. Thank you for sharing your experience with us. Just because I am aware of time and we are a bit tight on time tonight, so I am just going to move on to Fery. Fery, would you mind introducing yourself to tonight’s group?
 
 
Feryanto:
 
Sure, okay. Thanks everyone for having me first of all. My name is Fery and I am 32 years old and I am from Indonesia, but my background is Chinese so you can call me Chinese-Indonesian. I have been living in Sydney for four years, so I think I am a recent migrant. And previously I lived in Jakarta, the capital city of Indonesia for nine years. And I have been taking PrEP since 2018, so about three to four years now, and actually I know about PrEP firstly from Grindr which is the gay social App, and the reason is because I think of myself as a gay man. I have an active sex life and also at the time we had research so I was volunteering myself for participating in research from The Kirby Institute I believe. And yes, I think that is it for introduction from me.
 
 
Vincent:
 
Great, thank you, Fery. I was just again, I accidently asked Paolo this question. But, because it is so important to get an idea of the challenges faced by people who have recently arrived in Australia in terms of accessing PrEP, and so would you mind sharing sort of your experience of what you found helpful or less helpful when trying to access PrEP? You mentioned that you found out about it through Grindr, but in your interactions with medical professionals since then, what has worked for you and what have you found to be a bit of a challenge?
 
 
Feryanto:
 
I think if you are talking about migrants it depends on where they are from. From my personal experience, because Indonesia is majority Muslim, and there is a lot of stigma and shame when you are talking about STIs or even HIV, I think like, people still think HIV is contagious and like a death sentence, and because most people are religious, so it is always like related to you know, like something like a curse, like bad people or maybe a sex worker. So, I think in answering your question, I think the hesitation is because the culture back in the home country makes it like a shame to go to see doctors or accessing sexual health clinics. I think it is the mindset. So, first of all I think like ACON, I think is a really good organisation that creates like a safe place as in like a community for recent migrants so they can like feel, you know, unlearn all the shame and the stigma and they feel comfortable to start assessing and finally to get PrEP or even to get regular testing. So I think community and organisations are really important to be welcoming to all recent migrants to Australia.
 
 
Vincent:
 
Thank you, Fery. I think you already alluded to some of the difficulties that people face as a result of their own cultural background. Do you, I image you probably have friends from your own cultural background as well. Have they told you about any of their experiences? Because you mentioned ACON which obviously is in the middle of Sydney, but do any of them live in sort of more outer suburbs and have they found sort of different challenges as far as you know?
 
 
Fery:
 
Yes, I think if you are talking about Sydney, I know some friends who live in outer Sydney or even like the outer west. I think they also, and especially coming from a certain background, I think they also feel scared of getting all the information and also they do not have enough sex education and awareness, but ironically they are still are engaging in a very active sexual life. I think for me, I always like to ask people, are you on PrEP and what is your status? Just because I want them to know that I am on PrEP, and negative, and like even some of them using the term, like oh I am clean. So in that, you are saying the opposite of clean is dirty, I mean like nobody wants it to be said that he was dirty or something, but he meant that clean is like clear from STIs and everything. I mean I get that but I thought like that was such a bad term to use. But I also asked them that okay, so when was the last time you got testing and they are like, what kind of testing? So like, I try to say oh, did you get STI testing or HIV testing, because you said you are clean, and they say like, they are thinking are for a while and they say oh maybe, perhaps sometime in the last year. And then so like actually in my opinion, they do not have regular testing because they do not have proper sex education, also they feel sacred, also as I see in Sydney, we are so concentrated in the city area and I think inner city, I am not really sure if people who lie in like outer Sydney do they have like a proper sexual health clinic which they can access or where they could still get like discreet to access to the sexual health clinic. So I think that is really important. I think even in Sydney, people from outer Sydney are actually they are like my friends who are from Indonesia who are scared, who are having no sex education but still engaging actively in gay sex and having many multiple casual partners.
 
 
Vincent:
 
Yes, I think you make some very good points, Fery and there are some very particular challenges to addressing HIV rates amongst people who are from different cultural backgrounds, which we will touch on again. I am just going to move along again for time to our next section. I have just got some questions, well I have got the poll up here again. So I just thought I would gather from everyone who is here tonight, how often do you prescribe PrEP? So if you can click on those buttons for me, and in the meantime I am going to move along and ask Mirian and Treeni, who is in my field of vision? I will start with Treeni. Treeni what would you say is easy about prescribing PrEP and what successes have you experienced?
 
 
Catriona:
 
Well the PBS listing has made it much easier. The fact that people can access it even they do not have Medicare is also good. The personal importation, it is made a lot easier for a lot of international students to access PrEP and that is one group that we see a lot of.
 
 
Vincent:
 
Sorry, Treeni, can you explain that a little bit more for the audience? People might not be aware?
 
 
Catriona:
 
Yes. So if even if patients are not Medicare eligible, they can still access PrEP. There are online sites where they can personally import generic medication, and this medication has been shown to be bio-equivalent to the brand name. It is completely legal and it works out to be much cheaper. So what happens is the patient goes online, there is PAN.org and I think we have a reference for that at the end of the slides.
 
 
Vincent:
 
Yes, and people will be emailed it.
 
 
Catriona:
 
Yes, you go on that. You upload your script to the site and you get sent it from overseas. And it works out to be you know, only just over twenty dollars a month. You can get all three in one go as well, all three months in one go rather than having to access one month at a time. The only issue is that you need to plan it in advance, because it takes a while for it to be sent. And it is unpredictable sometimes how long it takes. So that is very good. The fact that a lot of the PrEP information now is in other languages, it is not just in English makes it a little bit more accessible to people.
 
Successes we have had, is it has allowed us to engage with an at risk group. So, particularly those men who have sex with men, who may not have come in for care previously are now coming in because they are getting their PrEP scripts and they are having routine screening. So that is definitely a plus. It gives you the opportunity to implement other harm minimising issues. So, things like hepatitis vaccination, hepatitis A and B vaccination. You get to screen people. You get to talk to them about their partners, keeping safe, other concerns to do with STIs and you know, things like needle exchange, Hep C risk. So it allows us to talk to them about those sorts of things. And it is a good opportunity to talk about other options, so treatment of prevention for people who are already HIV positive. Educate people about the risk, the real risks of HIV. Talk to them about condom use because people sometimes still use condoms, strangely enough. And we have also identified some very early infections, so people who are HIV positive, who would not have gotten tested otherwise, but they have come in because they want PrEP and we have screened them. So that is really good.
 
 
Vincent:
 
Thanks, Treeni. Miriam, did you, from I guess a GP perspective, any particular challenges or successes that you wish to share with us tonight?
 
 
Miriam:
 
I just think one of the successes I talk about is the fact that we actually have, my experience in my own community is the person coming in and requesting PrEP. So the community themselves being informed and confident enough to come and ask me to prescribe PrEP and so that has been a really positive success story. Like Treeni, the opportunity when people do present to have conversations about ongoing safe practices but also offering general screening tests that they may not have turned up for except they are after PrEP. They have heard about it through online sites or through their mates. So that has been a really positive success. I guess one of the challenges I face as a rural GP is people knowing that they can come and approach any GP for PrEP and making that widely known, I think that is always a challenge, but it is something that we really can overcome quite easily because one of the things I do find is while I am an infrequent prescriber, is following the steps that are on the New South Wales decision-making tool, the ASHM tool, makes such a difference and I can just do what I do with lots of things in general practice. As we know, we are jacks of all trades, masters of none, but we keep resources handy and those sorts of tools mean if someone approaches me for PrEP I can look that up at the time and feel confident that what I am doing is up to date and easy.
 
 
Vincent:
 
Thanks, Miriam. I am going to see if we can put that tool up on screen, because it is very handy and I think it is particularly important, and this has come up in the chat box a little bit. And as you said, you know it is very difficult to remember what you need to do in these sorts of scenarios when you do not routinely prescribe PrEP. So, here you go. You can all breathe a sigh of relief. There is a tool available online from the Australasian Society for HIV Medicine which very easily, in a step by step fashion, explains to you how to prescribe PrEP. So you literally walk through these steps. As you can see here at the top, it is 1, 2, 3, 4, 5. It tells you what you need to do at each step. For those of you who are less familiar with PrEP I will just very quickly run through it. Step one is identifying that someone needs PrEP. So either they come to you and they ask you for PrEP, or you have identified from your consultation with them that they would benefit from PrEP. So for example, they might disclose that they use substances, particularly crystal meth in the context of sex, or you have diagnosed them with a sexually transmitted infection, and you go hang on, I think you are at risk of HIV. Let us do something about that. So that is step one.
 
Step two is working out whether they are clinically suitable to have PrEP. So you do an HIV test to make sure they do not have HIV already. You check their kidney function tests. And so basically they are HIV negative and they are at risk of HIV then they are clinically suitable for PrEP. And then, sorry I am just getting ahead of myself.
 
So step three, you move through and you need to, oh my God, so you do kidney function test, make sure they do not have renal impairment. And that is probably, we used to be really worried about renal function tests when we first started with PrEP. We were really worried that we would see renal toxicity from PrEP. That is because the tenofovir in the PrEP medication can potentially be renotoxic. But I would like to stress to all of you that experience has shown over the last few years, and having had thousands of people on PrEP around the world, if not hundreds of thousands of people on PrEP around the world, that renal toxicity has not borne out to be a major concern. So we certainly still do a renal function test at the start and then we do that every six months but please do not feel afraid to prescribe PrEP because you are worried about renal function and renal function risk. PrEP has been shown to be generally a very safe intervention.
 
The next step, step three is to do STI testing. And as Evan here in the chat box said, you know what are we seeing? Have we seen an increase in STIs among men who have sex with men attributable to PrEP? We certainly have seen a massive increase in STI screening amongst men who have sex with men thanks to people being on PrEP, so that has been a big plus from the big PrEP rollout, and as a result of increased screening, we have also seen increased STIs. There have been some quite solid analyses looking at you know, is this due to PrEP or is this because of increased screening? The jury is still somewhat out, but I think it is better to say we have not seen the explosion in STIs that some people were worried about. But certainly STI screening is part of the monitoring. Under step three it also talks about hepatitis B serology and hepatitis C serology and then you just go on and prescribe the PrEP. So, there will be a link to this in the email that you will get but it really makes it very easy, so I just wanted to highlight how easy it is to prescribe PrEP. You can all do it. And hopefully by the end of tonight you will all feel confident to do it.
 
Treeni, did you want to talk about the changes to PBS?
 
 
Catriona:
 
Yes. So PrEP prescribing is now just a usual script. It used to be on authority but it is no longer authority script, which makes it a lot easier. Any GP, any doctor actually in New South Wales, in Australia can prescribe. So it is much easier. Also the guidelines have relaxed. You only need to have an HIV negative test some time within the 28 days. So if your patient has not had a test recently and they have not had any high risk exposure in the last 72 hours, you can start prescribing PrEP and take the HIV test then and wait for the result. One of the initial concerns about doing that was starting someone on PrEP who was already HIV positive, with the risk of development of resistant virus. But that has been shown to be not of concern, not significant. So as long as they are having a test at some stage, prescribe away. As Vincent said, it is really, really easy. As far as renal issues go, we have hundreds and hundreds of people on PrEP and we have had nobody who has had to immediately stop for an emergency renal issue. We have monitored people’s renal function and we have seen in a very small handful of people their renal function drop. That is their eGFR. But once you remove all the other – some of these people are on enormous amounts of protein shakes and supplements so they look like Dolph Lundgren if you are old enough to remember who Dolph Lundgren is. You know, so they look like they have got walnuts stuck under their shirts sort of thing. But once you remove all of that, most people, the very, very large majority of people go back to normal.
 
 
Vincent:
 
Thank you, Treeni. Now, sorry Bethany if we could show the poll results, that would be great. So we here we go, these are the poll results. 50% of you have never prescribed PrEP. That is very exciting. And the reason I am so excited about it is that hopefully after tonight you will feel confident to do it and will soon prescribe your first PrEP prescription.
 
 
Catriona:
 
There should be a competition, Vincent.
 
 
Vincent:
 
Yes, we should run a competition.
 
 
Catriona:
 
And the winner gets to listen to the webinar again.
 
 
Vincent:
 
No, they get to host the next webinar. So, Miriam, just over to you. Again from a GP perspective, in terms of the logistics of doing this during a GP consultation, have you got some wisdom to share with us?
 
 
Miriam:
 
So I think that is right, isn’t it? One of the things that is often sited as a reason for not taking up something like PrEP prescribing is that we worry about time. But really it can be integrated into any consultation, so I think one of the most important ideas is that this can be done in two steps. So you can see the person, have the conversation. As Treeni just said, if you feel that they are at risk and you get an HIV test in a few days, start the PrEP then and there, but get them back to have a talk and the STI screening done so you can talk about those results. So it can be divided from one consult into two consults, or you could if you have got time, a longer consultation. I think the other advantage is, if you space the consultations, someone comes in and they are asking about PrEP and you are not sure, you can actually just pause, like we do for lots of our other consultations that we do infrequently, get the information in your hands and understand what you are doing before you pass that information on to your patients. And for example, you could call the New South Wales Sexual Health Info Line then and there with the patient with you to ask the questions, or call your local sexual health clinic. Even though you may be in a more remote rural town, there will be a sexual health clinic somewhere, there are quite a few of them around the state, so you can call one of those to have a bit of a conversation and get some advice. So I think you know, you have got resources that you can use. We have got online resources, we have got on-phone resources and we have got colleagues that we can call.
 
 
Vincent:
 
Yes, thank you. And I agree, phone a friend is always a good option and people are certainly welcome to phone their nearest sexual health centre for advice as well if you ever feel like you are getting stuck. Great. So, sorry I am having a look if there are any questions come in. So, Treeni, have you, sorry I am just going through, just working out timing wise, how we are going. So just going back.
 
 
Catriona:
 
I would just like, sorry while you are looking at questions, I would just like to reiterate what Miriam was saying. It is quite easy to streamline the PrEP issues. We have a cheat sheet that we use, that we just tick off, that we have done the test. We give the patient the request form and they do and do the testing. We do not need to have the results to keep continuing their PrEP. So it is just come in, how are things? Let us do your screen. Here is your script. See you later.
 
 
Vincent:
 
Yes. And I think you know, in general practice, what I used to do was I had you know, all of general practice software has the capability of having templates, drop in templates for your progress notes, and what I used to do, granted I used to see a lot of PrEP, but I had a drop in template for the first PrEP consult, to cover all the things that I needed to talk to the patient about and the tests that I needed to do, and then a template for follow up consults. And it does make it a lot easier. I am sure you are all very familiar with that for lots of different conditions and lots of different plans for people’s different health conditions. Miriam, is that something that you use?
 
 
Miriam:
 
Absolutely. So we have autofill set up and I think for conditions that you are not doing frequently, those checklists can be most useful and just good reminders. You can also set up on your pathology, an actual PrEP request and you have pre-populated with the tests that are required each time, so again streamline the consultations, so I think that is a very useful tip.
 
 
Vincent:
 
Yes. Thanks. Sorry, the reason I am sort of scanning over programs that we have already covered a few things that we were going to cover. But Treeni, we talked a bit about men who have sex with men from culturally and linguistically diverse backgrounds who are maybe less engaged with the mainstream gay community, and that results in reduced knowledge of HIV as Fery pointed out. Do you have any tips on how GPs can engage around this and what their role might be in this?
 
 
Catriona:
 
Yes. Yes, definitely. The first thing is to be open to PrEP and to let patients know that you are open to discussing it and that you are willing to have that conversation and you are not going to judge. I mean, coming from different cultural backgrounds, people have different understanding about what the medical system is, so navigating that can be very difficult to begin with, particularly when you do not speak the language. Knowing what to ask, there is also that fear of judgment and discrimination. In a lot of different countries particularly, I am Chinese, the doctor is up here and the patient is down here. Now, that is very difficult then to go in and to ask for something, or to discuss very personal information. So you really do need to be open and even something as simple as bringing up the topic with your patient can really break the ice there and say, I am willing to have that conversation and go there with you. The payment can be difficult as well. So alerting your patient that you are open to that discussion, and that might be as simple as just having a poster in your waiting room, having some fliers in the front desk. Word of mouth is really important as well. For a lot of our non-English speaking patients, we will say to them you know, if anyone you have sex with, if they are worried about HIV, they can come here as well. We have interpreters, blah, blah, blah, we can phone interpreters. So that is not a problem. But for some of the CALD backgrounds, they do not have Medicare and we have talked about how to access that elsewhere.
 
 
Vincent:
 
Thanks, Treeni. And Miriam, I guess over to you with this because I imagine there are similar challenges in rural and remote communities around people finding it difficult to access HIV information or to know where to go with the HIV risk. Do you have any wisdom you would like to share with us around making this accessible for people in rural and remote communities?
 
 
Miriam:
 
Look, I think similarly to Treeni, the notion of having posters up, having brochures in the waiting room highlights that you are open to conversations. Being very clear and open to questions and picking up on cues that patients might give you is really important too, and non-judgmental language. I think one of my lessons over time I have learnt is that knowing sexual behaviour is not always static and people may change between visits and have different notions about their sexuality that they are prepared to share with you as they get more comfortable with you, and I think it is really important to be open as a GP to such changes and just use language that is very sensitive. I think the other issue in rural settings is around confidentiality and in some ways we are a bit privileged in general practice, because someone can be coming to see us for any reason. So is it necessary to clarify that they are coming to see us for PrEP or for sexual health check-ups or for HIV information, and that is a positive I feel. The other one though of course is being very, very careful with confidentiality, both within the practice and even in the greeting and see out of patients. So I think those sorts of notions can make it really important. I cannot stress enough about the importance of being non-judgemental. And in our area for example, we see a lot of Aboriginal patients and I have had an Aboriginal health worker really reiterate to me over many years, it is so important not to use the excuse of not feeling comfortable or saying you do not know how to ask a question as a reason for not giving care. And that is so pertinent in a rural area because there may not be another place that person can go and get care.
 
 
Vincent:
 
Thanks, Miriam. There is a significant distinction between your setting and Treeni’s setting. Treeni works in a sexual health clinic where people come in expecting to receive sexual health care. But as a GP, I imagine, and I certainly found his myself when I was a rural GP, it can be difficult to ask questions about sex and sexual history and work out whether someone indeed has a HIV risk to start with. If they are not identifying that risk themselves. Do we have any quick, we do not have a lot of time, but do we have any quick tips for people on how to broach this topic?
 
 
Miriam:
 
I just think one of the important issues is to normalise the asking of the question, just to make it a normal part of general good health. So you know, we ask smoking history. We ask alcohol and drug history. We also ask sexual histories. And we ask it in a non-judgmental way and we ask it regularly of patients so people get used to it. So that would be my biggest tip overall, the more confident we are that we are asking for reasons to give good health advice for a holistic approach to this patient’s care, it gives us confidence and it will help the patient understand that we are doing this. You know, I ask all patients who come in these questions, a few of these questions are a bit private, would it be alright if I bring these up?
 
 
Vincent:
 
Yes. And I think that is a really important point, Miriam and I think, I do not want to over-emphasise this, but it is great that everyone is here to learn about PrEP but if people are not taking sexual histories routinely, then it is going to be very difficult to identify patients who need PrEP. That is why I just wanted to emphasise that. We have talked a lot about men who have sex with men. I just need to point out that PrEP is not only for men who have sex with men. PrEP is available for anyone who is at risk of HIV, and that may be heterosexual women, it may be heterosexual men, it may be trans and gender diverse people, and it may indeed be people who inject drugs who may be at risk of HIV. Now in the PrEP tool that we pointed out before, there is some advice on which particular patient types would particularly benefit from PrEP, so I encourage you all to look at that tool when it gets sent to you after this workshop.
 
Now, we are just going to think about accessing PrEP for consumers. And, we have kind of already touched on this, but Treeni do you have anything to add on which communities or groups we see a lower PrEP awareness in, in your experience?
 
 
Catriona:
 
Oh, in my experience it is definitely the non-English speaking people at risk. Also, people who are newly arrived from overseas. Students, tend to be, a lot of the students around my area tend to be less aware. And people who are not as engaged with the gay community. So they do not get that health promotion messages. So they may be people who identify as heterosexual who have sex with men for example. Or from outside of the, I was going to say ghettos, probably not the right thing to say, is it? Outside of the inner city area. So we are on the North Shore, and my area stretches all the way up to Hornsby and there are areas within my Local Health District such as the Northern Beaches, around Hornsby, Epping area where there are men who have sex with men, and other people at risk of HIV but they are not engaged with the gay communities. So they do not get that health messaging.
 
 
Vincent:
 
Yes. All important points. And just quickly, because I would like to address some of the questions that are in the chat box, but before we move to them, Miriam, rural and remote settings. Any issues with regard to getting access to the actual medication itself from your local pharmacy?
 
 
Miriam:
 
So in my particular area, there is not, and I guess one of the ways of finding out is by ringing your local pharmacist and seeing who has got access to it. But if there were issues, and some of them might be around privacy, particularly in very, very small towns where the person wanting to access PrEP knows the pharmacist or is worried about the information getting out into the community, and they would not be comfortable with that, there are two ways of doing that. There is the online service that Treeni mentioned, but the other way is to use a pharmacy in another town and we certainly have used those habits in the past for accessing medications for other reasons, but I think you know, one of the clues I learnt early on is just ring your pharmacist. Someone around will have it. Someone around will be familiar with it because it is becoming more common.
 
 
Vincent:
 
Yes. And you know, if they do not have it, they can order it in and usually pharmacists can get medications in within 24 hours.
 
 
Miriam:
 
Absolutely.
 
 
Vincent:
 
I guess also, it would be sometimes in rural communities it is important to ring your pharmacist not only to ensure that there is a supply of medication but also to make sure that the patient themselves do not have a negative experience of going to the pharmacist to obtain that medication, particularly as you said, when issues of confidentiality may be problematic in country towns.
 
 
Miriam:
 
Absolutely.
 
 
Vincent:
 
One of the questions in the chat box, sorry we are going a bit off script here, but one of the questions in the chat box is from David. And David asks, and Treeni I am going to throw this to you, David asks can PrEP be taken daily forever, ideally to be monitored but if you know the patient will not come back, is it safe to give them a long term script? How would you reply to that?
 
 
Catriona:
 
Okay. So, look it is thought to be, the whole theory behind PrEP is that people take it when they are at risk, and that risk will change over time. So, somebody might be out there, you know, there are no restrictions, there is no mask wearing, people are going out and having fun and they are having a lot of sex. And then they meet somebody. Or there is lockdown, so they stop. So, it is thought because people’s sexual activity is dynamic that their PrEP use will change with that. It can be taken ongoing without risk so long as it is monitored. PBS wise, you can only give up to three months of medication at a time. And that encourages people to keep coming back for screening in particular and monitoring. And looking not only for HIV, we are also looking for STIs. I would be reticent to give somebody a long term script or long term medication unless there was a particular reason. But at the moment I cannot actually think of one given that nobody can travel anywhere. So, there are other ways to take PrEP also, so standard is daily. Anyone can take it daily. But if you are a cis man who has sex with men, so if you are the same gender, if you are male gender and you were male gendered at birth, and you only have sex with men, then you can take PrEP on demand and I think we have got a video about that later on.
 
 
Vincent:
 
Yes, I think the video will be sent out by email, but I guess just to point out that ASHM, the Australasian Society for HIV Medicine has also produced a decision tool around on demand PrEP for men who have sex with men, which is also available on the website, and we will make sure that that link is also included in the email that everyone will get. It is a bit complex to explain right now, but it is an option as Treeni said for cis gendered men who sex with men as opposed to trans gender.
 
Caroline said, is PrEP restricted to adults only and would you prescribe it for a sexually active 16 to 17 year old? Treeni?
 
 
Catriona:
 
Okay. So, no. For PBS listing, I think it is 18 years plus, but you can give it to younger people depending on their size and weight. But definitely in a 16 or 17 year old, you can prescribe it.
 
 
Vincent:
 
Yes, exactly. There is some guidance on this in the PrEP guidelines. The main concern has been because tenofovir can have an effect on bone density and there is very limited date on bone density in people who take PrEP during the phase of bone growth. So 16 to 17 year olds. But you, it becomes a risk-benefit calculation. So if someone is at significant risk of HIV, it is better to prevent their HIV acquisition than some theoretical problem with bone density.
 
 
Catriona:
 
Interestingly, there is PrEP data from case series and observational trials of PrEP in 12 and 13 year olds plus. So I do not understand why a 12 or 13 year old would need to use PrEP. I do not know, it sounds a bit awful. But there is data available.
 
 
Vincent:
 
Yes. Bronwyn said, if someone gets started on PEP from ED as a starter pack, can GPs prescribe PrEP to complete the course as 28 days, even if not an S100 prescriber? Now I am going to have a go at answering this question. So, you hopefully all know just as background, there is PEP, or post-exposure prophylaxis, and PrEP, or pre-exposure prophylaxis. PEP is reactive, as in if someone comes in to an emergency department for example and they say I had sex last night without a condom, or the condom broke and I am really worried about HIV, depending on the exact circumstances, they may be started on post-exposure prophylaxis which is a course of one tablet a day for 28 days for most people. For some people it might be two tablets a day. Now for most people, as Bronwyn said, it is Truvada one tablet a day which is the same tablet as PrEP. So, the guidelines do say, and the new guidelines emphasise more strongly that you as GPs can prescribe PrEP as PEP. So if someone comes to you and says I had sex last night with a new sexual partner, I am worried about HIV and you have a talk to them and you work out that there is a possible HIV risk, you can prescribe them PrEP to start immediately which essentially is the same as starting PEP, or post-exposure prophylaxis. It is, and it says this in the prescribing tool, it is recommended that you make contact with your local PEP service and the phone numbers for those are online, just to double check that it is okay in that particular scenario. But I think it is a really important point, thanks Bronwyn for bringing it up, that you can now, and you do not need to be an S100 prescriber. As Treeni said, any doctor in Australia can prescribe PrEP, but basically as a result of that you can now also prescribe PEP in most scenarios when people need it.
 
The next question is from Luna who said, for on demand, if you just take it for one day, will it work immediately? Luna, I will very briefly answer that question for you. So on demand PrEP again, is only for cis gendered men who have sex with men and that is not because of any sort of reason that we do not want to prescribe to anyone, but it is because the trial data only comes from that population. The only successful on demand PrEP studies were among men who have sex with men. The protocol is two tablets of PrEP, so two tablets of Truvada, so double dose, at least two hours before sexual contact followed by one tablet 24 hours later and one tablet 48 hours after the first dose. And that is one course of on demand PrEP. I will not go into it in more detail because then obviously you need to work out how you go from there. But basically that works, and that works really well. So at least two hours before sex.
 
The next question is from Gugus. I hope I pronounced your name correctly. Gugus asks about confidentiality. If a patient has asked not to disclose his test and it comes back positive, then I should notify HIV. What should I do if he refuses to proceed with testing? Treeni, do you have any wisdom to impart?
 
 
Catriona:
 
Yes, sure. So not to disclose if he is – okay so, HIV there is enhanced surveillance for HIV infections. It is done on a two by two code. So the patient’s identity remains anonymous or confidential. Also with the testing, the positive test gets sent as a part of a notification by the lab. So, basically it is done. I think the patient just needs to know that they are de-identified and it is just the case and the two by two code, date of birth.
 
 
Miriam:
 
Postcode?
 
 
Catriona:
 
Postcode, yes.
 
 
Vincent:
 
I think that is really important, Treeni. Thanks for highlighting that, that the notification, the HIV notification is not in the patient’s name, it is two by two code. So letters of their first name and two letters of their surname. So if they are really worried about confidentiality, you can often reassure them that their name would not be used. And I would strongly counsel patients to not see that as a barrier to testing, because then they will miss out on HIV testing forever.
 
So, let us move on because, oh my God, we have already run to 8:30 and we are having such a good time everyone, we wanted to keep going. Thank you all for so many questions. So, here are the resources which will all be emailed to you. I guess, just to wrap this up, and I will throw to the panel as well if there are any additional points to impart to the audience. But I just wanted to wrap up and say that what we have really tried to highlight tonight is that PrEP is really safe and it is really effective and prescribing it is really easy. And for people who are at risk of HIV it can be one of the most important things that you do for that person ever if you can prevent them from acquiring HIV. And we particularly need your help in reaching the more difficult to reach populations, so people from culturally and linguistically diverse backgrounds, people who do not identify as gay, people who do not live in the cities, who do not access sexual health centres. People who access sexual health centres and people who are engaged in the gay community, most of those people are already on PrEP, we have already got those people on PrEP. We need your help to try and reach those people who we cannot reach. And as I said, and I cannot highlight it enough, I urge you all to have a look at the ASHM PrEP prescribing tool because it really does show how easy it is to prescribe PrEP. What we have also tried to highlight is the suitability criteria for PrEP have been broadened, which means that more people are eligible for PrEP in recognition of the fact that we need to deliver more PrEP in the community to anyone who is at risk of HIV if we are going to achieve our end goal which is to have no more new transmissions in New South Wales. Another point is that we need to increase access to PrEP for the patient groups that we talked about and really that it is. And the resources are going to be sent to you.
 
Now just to throw back to the panel. Is there anything else that any of you would like to add to tonight’s discussion? I do apologise to our consumer participants, I wish we had had more time to talk to you as well, but it has been quite a rush.
 
 
Miriam:
 
I think just the point that you made. The thing is that prescribing PrEP is easy. It can be done by all GPs and the tools are out there to make it streamlined for us.
 
 
Vincent:
 
Yes, and I think, sorry to keep talking, I think Miriam the point that you made earlier is really important, for people to try and find a way to make sexual history taking a routine part of history taking with every patient. And I think that last bit, every patient is really important because people change. People might have been married for years and then for some reason, you know a guy might have been married to his wife for 20 years and all of a sudden starts having sex with men. Unless you routinely take sexual histories, you will not know that and he may not be comfortable coming to you to talk about his sex life, so taking that ownership and running with it. In my experience, I have never had anyone object to the fact that I asked them about their sex life. If anything, the reaction I tend to get is one of relief, of people knowing that it is a safe space to talk.
 
 
Bethany:
 
Alright, well I might wrap us up for this evening. Before we go, I just wanted to say a big thank you to our panel this evening, thank you Vincent, Miriam and Treeni and also a massive thank you to Fery and Paolo for coming here tonight and sharing your experience. And thank you to everyone online who have submitted questions and gotten involved with tonight’s presentation, it is really appreciated.
 
 
 
 
 
 

Other RACGP online events

Originally recorded:

22 June 2021

This online forum provides GPs with an opportunity to share their experience of prescribing PrEP, with the aim of further developing confidence and skills. The forum will involve patients who have been prescribed PrEP and advice from specialists.

Learning outcomes

  1. Consider recent updates to HIV pre-exposure prophylaxis (PrEP) prescribing, including broadening of suitability to increase access to anyone at risk of HIV
  2. Improve confidence in PrEP prescribing or follow-up through the sharing of GP experience, patient experience and specialist advice
  3. Learn methods to overcome challenges or barriers to prescribing PrEP
  4. Identify tools and resources available to support PrEP prescribing in NSW
This event attracts 2 CPD points

This event attracts 2 CPD points

Presenters

Dr Catriona Ooi
Director, Northern Sydney Sexual Health Service

Dr Vincent Cornelisse

BSc(Hons), MBBS, FRACGP, FAChSHM, PhD Staff specialist in sexual health medicine, Kirketon Road Centre - NSW Health Conjoint Senior Lecturer, The Kirby Institute – UNSW Clinical Advisor - ASHM

Advertising

© 2021 The Royal Australian College of General Practitioners (RACGP) ABN 34 000 223 807