This document summarizes an E-learning discussion on PrEP clinical management. It discusses: - Special clinical situations including adolescents, pregnancy/breastfeeding, hormonal contraception, elevated creatinine, hepatitis B, HIV seroconversion, and recreational drug use. - Key counseling messages for clinicians around PrEP safety, effectiveness, and avoiding stigma. PrEP is described as safe and effective when used properly, and clinicians are advised to reduce stigma. - Two expert panelists - Dr. Jason Reed and Dr. More Mungati - who have extensive experience in HIV prevention, programming, and research. The discussion was moderated by Dr. Seema Ntjabane.

1. PrEP E-learning Discussion II
September 24, 2020
2:00-3:00 p.m. SAST
Expert Panelists:
• Dr. Jason Reed, Biomedical HIV Prevention
Technical Advisor, Jhpiego
• Dr. More Mungati, STAR-L Director, EGPAF
Lesotho
Moderator:
• Dr. Seema Ntjabane, Care & Treatment
Specialist, USAID-Lesotho
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2. Housekeeping: How to Connect
to Audio by Computer
• Join using computer audio
and a plug-in headset or
computer speakers
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3. Panelists
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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.
Dr. More Mungati is a Public Health
Physician with more than 15 years`
experience in HIV/TB programming;
maternal, child, neonatal health;
health systems strengthening; and
research. He is currently the focal
person for PrEP within EGPAF
Lesotho supporting MOH and works
with EGPAF Global PrEP technical
working group

4. Special Situations Arising
for Clinical Management
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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
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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.
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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
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8. Clients on hormonal contraception
• HIV PrEP is safe and effective in clients
using hormonal contraceptives (whether
oral, injectable or implantable)
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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
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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
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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
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13. SAFETY
EFFECTIVENESS
AVOIDING STIGMA
Counseling Messages for
Clinicians
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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
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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
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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
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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
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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.
Dr. More Mungati is a Public Health
Physician with more than 15 years`
experience in HIV/TB programming;
maternal, child, neonatal health;
health systems strengthening; and
research. He is currently the focal
person for PrEP within EGPAF
Lesotho supporting MOH and works
with EGPAF Global PrEP technical
working group

19. Questions and Answers
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• 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
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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.
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