PrEP Learning Discussion II
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The document outlines guidelines for managing special situations in clients taking HIV PrEP, discussing topics such as support for adolescents, safety in pregnancy, and handling elevated creatinine levels. It emphasizes the importance of regular HIV testing, proper counseling on PrEP effectiveness, and strategies to reduce stigma around PrEP use. Expert panelists Dr. Abiye Kalaiwo and Dr. Jason Reed provide insights, highlighting the need for responsive support to enhance adherence and overall health outcomes.
PrEP Learning Discussion II
- 1. PrEP E-learning Discussion II July 28, 2020 2:00-3:00 p.m. WAT Expert Panelists: • Dr. Abiye Kalaiwo, Program Manager, USAID/Nigeria • Jason Reed, Biomedical HIV Prevention Technical Advisor, Jhpiego Moderator: • Olawale Durosinmi-Etti, JSI Nigeria 1
- 2. Housekeeping: How to Connect to Audio by Computer • Join using computer audio and a plug-in headset or computer speakers 2
- 3. Housekeeping: Connecting by Phone, Using Video • You will begin muted. To unmute/mute click the Microphone icon • Click Start Video to join by webcam. But be careful if you have a low-bandwidth as this may slow your connection down or disconnect you completely. 3
- 4. Special Situations Arising for Clinical Management 4
- 5. Clinically managing special situations arising in PrEP clients 1. Adolescent/young adult (< age 25) clients 2. Pregnancy or breastfeeding 3. Clients on hormonal contraception 4. Elevated serum creatinine/decreased creatinine clearance (<60 mL/min) while using PrEP 5. Clients with hepatitis B 6. Seroconversion after starting PrEP 7. Clients injecting or using recreational drugs 5 5
- 6. Serving adolescents & young adults • Make efforts to provide additional/flexible/non-judgmental support – Adherence with dosing – Contact need not always be in person – Access to additional services like pregnancy testing, contraception, mental health, substance use and social support. 6
- 7. Pregnancy or breastfeeding • It is safe to continue taking PrEP • Becoming pregnant (or beginning breastfeeding) further increases women’s risk and the benefits of PrEP 7
- 8. Clients on hormonal contraception • HIV PrEP is safe and effective in clients using hormonal contraceptives (whether oral, injectable or implantable) 8
- 9. Elevated serum creatinine/decreased creatinine clearance while using PrEP • Approx 80% of abnormal creatinine results resolve without stopping PrEP; re-test creatinine by redrawing blood on different day • Consider discontinuing if separate blood specimen test result is still abnormal – A serum creatinine elevation – A decreased creatinine clearance < 60 mL/min • Creatinine elevations usually reverse after stopping PrEP – Once PrEP stopped, recheck creatinine and offer PrEP restart if results normalized – Creatinine abnormalities usually do not reoccur after PrEP restart 9
- 10. Hepatitis B • Stopping HIV PrEP in a client with hepatitis B can result in a resurgence of hepatitis B virus, called a “flare.” – may occur 1 to 3 months after stopping – often limited to elevations in ALT and AST • Hepatitis flare from discontinuing PrEP treated by restarting tenofovir/TDF 10
- 11. HIV Seroconversion • WHO recommends confirming the HIV diagnosis in PrEP clients by testing second blood sample • If an HIV diagnosis is confirmed, offer client fully suppressive HIV antiretroviral therapy—ART—as soon as possible; do not delay – Only ~3% of PrEP recipients HIV seroconverting had resistance to TDF or FTC – Second-line ART regimens for seroconversion after starting PrEP usually not required11
- 12. Injecting/Using Recreational Drugs • Main approach to HIV prevention is harm reduction strategies - opioid substitution therapy and needle syringe programmes • Clients using/injecting drugs may also be at risk of sexually acquiring HIV and benefit from oral PrEP – But oral PrEP is not a substitute for OST or syringe programmes 12
- 13. SAFETY EFFECTIVENESS AVOIDING STIGMA Counseling Messages for Clinicians 13
- 14. Counseling Clients about PrEP Safety • PrEP is safe when used by HIV negative people, so we must re-test for HIV every 3 months (and ideally 1 month after starting) • There are no side effects in most people; about 10% may experience side effects (stomach upset, headache), typically mild and resolve without stopping PrEP • Rarely, PrEP may cause problems with kidney function or the hardness of bones o Let me know if you have a related medical condition or history • If you have hepatitis B, daily PrEP use may still be safe o Before stopping PrEP, you should speak with me or another health care provider, since stopping may cause hepatitis B infection to worsen • It is safe to take PrEP throughout pregnancy and breastfeeding 14
- 15. Counseling Clients about PrEP Effectiveness • PrEP highly effective at preventing HIV (~90%) when used as prescribed o Easier to take if a daily habit, when brushing teeth, going to bed; If you forget, take it as soon as you remember • For STARTING and STOPPING PrEP o Needs to be taken for 7 days before you’re protected against HIV o Should be taken for 28 days after last possible HIV exposure/high risk sex for maximum protection 15
- 16. Counseling Clients about PrEP Effectiveness • PrEP still protects against HIV even if you’re taking it with alcohol or recreational drugs o Though taking alcohol and drugs may make is more difficult to remember to take PrEP • Using condoms and/or contraception is still a healthy choice; your use of PrEP for HIV prevention does NOT: o prevent other sexually transmitted infections o prevent you or your partner from becoming pregnant 16
- 17. Avoiding Stigma • PrEP clients often stigmatized – PrEP health care providers can help clients and influence communities to view PrEP as a responsible choice to help protect health – Reducing stigma may increase uptake of PrEP, daily adherence, and impact on HIV epidemic – Seek special training, if needed, to ensure clients don’t feel judged for their reasons to seek PrEP, including if they are not comfortable disclosing17
- 18. Panelists 18 Dr. Abiye Kalaiwo is a Public Health Specialist and USAID's Nigeria's technical lead for Key Populations, managing PEPFAR's single largest Key Populations program. He has over 12 years experience in HIV and infectious disease programs at the national level. Dr. Jason Reed offers more than 12 years of experience in public health surveillance and medical epidemiology, specifically in HIV surveillance systems, prevention programming, and implementation research at state, national and international levels.
- 19. Questions and Answers 19 • Type your questions and comments into the Chat box • We will try to get through every question. –We will ask our speaker to provide answers for any questions not covered during this webinar. We will distribute these answers to all participants.
- 20. Evaluation Survey 20 We have put a link to the survey in chat. We will also be sending the link when we send out a link to the slide and Q & A. We truly appreciate in feedback so that we can continue to improve these sessions and make them useful.
- 21. Thank you. 21
Editor's Notes
- #8: The medications in PrEP regimens have been widely used in HIV treatment in HIV-positive pregnant and breastfeeding women, and they have shown to be safe. In a study that included HIV-negative women in serodiscordant relationships, there were no differences in birth outcomes, infant birth weight, and congenital malformations in women using PrEP versus placebo.
- #10: Stopping TDF-containing PrEP is typically sufficient to restore baseline renal function. Additional causes and management of serum creatinine elevations should be considered, especially if any of the following are present: - Serum creatinine elevations are greater than 1.5 fold the upper limit of normal - Increased serum creatinine/decreased creatinine clearance do not return to normal levels within 3 months of stopping PrEP - Abnormal creatinine results worsen ≥ 1 month after stopping PrEP In such cases, consider known causes of chronic or severe renal insufficiency, which are rare in PrEP using populations (e.g., diabetes mellitus, uncontrolled systemic hypertension, hepatitis C virus (HCV) infection, liver failure, and pre-eclampsia during pregnancy).