Pre-exposure prophylaxis (PrEP) involves using antiretroviral medications like Truvada to prevent HIV infection in HIV-negative people. PrEP is highly effective if taken consistently before and after exposure to HIV. It works by preventing the virus from establishing a permanent infection during the window of opportunity after exposure. PrEP is recommended for those at high risk of HIV infection, including men who have sex with men, transgender individuals, injection drug users, and heterosexual men and women with multiple partners or other risk factors.

1. PRE-EXPOSURE
PROPHYLAXIS (PREP)
BRIG (DR) HEMANT KUMAR
PROF & HOD COMMUNITY MEDICNE
AJIMS & RC MANGALORE

2. 4/4/2019 2BRIG HEMANT KUMAR

3. 4/4/2019 BRIG HEMANT KUMAR 3

4. 4/4/2019 BRIG HEMANT KUMAR 4

5. 4/4/2019 BRIG HEMANT KUMAR 5

6. 4/4/2019 BRIG HEMANT KUMAR 6

7. 4/4/2019 BRIG HEMANT KUMAR 7

8. WHY DID I SHOW YOU ALL THESE
PICTURES ??
4/4/2019 BRIG HEMANT KUMAR 8

9. 4/4/2019 BRIG HEMANT KUMAR 9

10. 4/4/2019 BRIG HEMANT KUMAR 10

11. PRE-EXPOSURE PROPHYLAXIS
(PREP)?
Pre
 Before
Exposure
When a fluid containing micro organism
comes into contact with mucous membrane or
non-intact skin
Prophylaxis
 An action taken to prevent infection or disease
4/4/2019 11BRIG HEMANT KUMAR

12. DEFINITION
What is PrEP?
Pre-exposure prophylaxis, or PrEP,
is a strategy that involves use of
antiretroviral medications (ARVs)
to reduce the risk of HIV infection
in people who are HIV negative.
4/4/2019 12BRIG HEMANT KUMAR

13. WHAT DOES PREP CONSIST OF ?
PREP includes use of one or two anti-retroviral
drugs by HIV-negative individuals starting
before an exposure and continuing afterwards
◦ A potential option to prevent infection from
ongoing exposures to HIV during periods of
risk.
A recently proven strategy still being studied.
4/4/2019 13BRIG HEMANT KUMAR

14. NAME THE DRUG(S) ??
4/4/2019 BRIG HEMANT KUMAR 14

15. 1. A combination of two HIV medicines
(TENOFOVIR AND EMTRICITABINE),
TRUVADA is approved for daily use
as PrEP to help prevent an HIV-
negative person from getting HIV
from a partner who’s positive.
2 Studies have shown that PrEP is highly
effective for preventing HIV if it is
used consistently.
4/4/2019 15BRIG HEMANT KUMAR

16. 4/4/2019 16BRIG HEMANT KUMAR

17. Are for oral administration, and are
available in the following strengths:
Film-coated tablet containing
1. EMTRICITABINE = 200 mg
2. TENOFOVIR = 300MG
As active ingredients.
4/4/2019 BRIG HEMANT KUMAR 17
TRUVADA tablets

18. 4/4/2019 BRIG HEMANT KUMAR 18

19. DOSES
1. Take Truvada with or without food at the
same time each day.
2. If you take Truvada for PrEP, take it every
day and not just when you think that you
were exposed to HIV.
3. Always combine use of PrEP with
condoms and other safer sex practices.
4. WHAT SHOULD I DO IF I FORGET A DOSE?
4/4/2019 BRIG HEMANT KUMAR 19

20. Truvada can cause serious, life-threatening side
effects. These include a build up of lactic acid
in the blood (lactic acidosis)
and liver problems.
CONTACT DOCTOR IF ANY OF FOLLOWING SYMPTOMS
1. Weakness or tiredness, Unusual (not normal) muscle pain
2. Shortness of breath or fast breathing/Irregular heart beat
3. Stomach pain with nausea and vomiting/dizziness
4. Hands or feet that feel cold or turn blue
4/4/2019 BRIG HEMANT KUMAR 20
WARNING

21. PrEP
Candidates?
4/4/2019 BRIG HEMANT KUMAR 21

22. PrEP Candidates
1. MEN WHO HAVE SEX WITH MEN (MSM)
WHO:
a. Have an HIV-positive sexual partner
b. Have a recent bacterial STI
c. Have a high number of sex partners
d. Have a history of inconsistent/no
condom use
e. Engage in commercial sex work
4/4/2019 22BRIG HEMANT KUMAR

23. ARE YOU A GUY WHO HAS SEX
WITH GUYS??
4/4/2019 BRIG HEMANT KUMAR 23

24. 2. Transgender individuals who:
Engage in high-risk sexual behaviors
4/4/2019 BRIG HEMANT KUMAR 24

25. 3. Injection drug users (IDU) who:
a. Have an HIV-positive injecting partner
b. Share injection equipment
c. Have been through recent drug treatment (but
currently injecting)
4/4/2019 BRIG HEMANT KUMAR 25

26. 4. Heterosexual women and
men who:
1. Have an HIV-positive sexual partner
2. Have a recent bacterial STI
3. Have a high number of sex partners
4. Have a history of inconsistent/no
condom use
5. Engage in commercial sex work
6. Live in a high-prevalence area or
network
4/4/2019 26BRIG HEMANT KUMAR

27. 4/4/2019 BRIG HEMANT KUMAR 27

28. 4/4/2019 BRIG HEMANT KUMAR 28

29. YES IF YOU….
Fit in?
4/4/2019 BRIG HEMANT KUMAR 29

30. IF YOU ARE GUY WITH MULTIPLE
SEX PARTNNERS ..
4/4/2019 BRIG HEMANT KUMAR 30

31. If YOU ARE A W OMAN W HO HAS
SEX W ITH MANY GUYS ??
4/4/2019 BRIG HEMANT KUMAR 31

32. IF YOU ARE A TRANSGENDER WHO
HAS MULTIPLE SEX PARTNERS
4/4/2019 BRIG HEMANT KUMAR 32

33. OR A DRUG USER ???
4/4/2019 BRIG HEMANT KUMAR 33

34. Lesbian …
4/4/2019 BRIG HEMANT KUMAR 34

35. OR A HOMO……
4/4/2019 BRIG HEMANT KUMAR 35

36. HABLA USTED ESPANOL??
4/4/2019 BRIG HEMANT KUMAR 36

37. 4/4/2019 BRIG HEMANT KUMAR 37

38. HOW DOES PREP WORK?
Infection does not occur instantly after an exposure
to HIV
◦The virus needs to spread throughout the body
◦This may take up to 3 days after the exposure
THE “WINDOW OF OPPORTUNITY” FOR PREP
◦ The brief period of time - after an exposure - where HIV
has not yet spread throughout the body
◦ DURING THIS TIME, PREP MAY BE ABLE TO STOP HIV SPREAD
4/4/2019 38BRIG HEMANT KUMAR

39. Rule out Acute HIV Infection
before PrEP
SYMPTOMS OF ACUTE HIV
1. Fever , Fatigue
2. Myalgia , Skin rash
3. Headache , Pharyngitis
4. Cervical Lymphadenopathy , Arthralgia
5. Night sweats , Diarrhea
4/4/2019 39BRIG HEMANT KUMAR

40. BARRIERS TO USE OF PREP
1. Eligibility
2. Adherence
3. Increased risky sexual practices
4. Side effects
5. Reimbursement
6. Patient accountability
7. Provider knowledge, comfort, and willingness to
prescribe
4/4/2019 40BRIG HEMANT KUMAR

41. CONCERNS WITH USE
OF PREP?
1. Side-effects and toxicity
2. Drug resistance
3. Adherence
4. Risk compensation
5. Access
6. Cost
4/4/2019 41BRIG HEMANT KUMAR

42. 2014 PrEP Prescribing
Guidelines
1. Determine eligibility: negative HIV test, high risk
of infection and creatinine clearance > 60ml/min
2. Assess for HBsAg and pregnancy (female
patients)
3. Prescribe : Tenofovir-emtricitabine (Truvada) one
pill once daily (90 day supply)
4. Monitor: creatinine clearance, HIV status, and
pregnancy every 3 months and STI screen every 6
months; counsel on adherence and risk reduction
4/4/2019 42BRIG HEMANT KUMAR

43. Before starting PrEP:
1. CLINICAL ELIGIBILITY
2. EDUCATE
◦ Side effects
◦ Limitations
◦ Daily adherence
◦ Symptoms of seroconversion
◦ Monitoring schedule
◦ Safety
◦ Criteria for discontinuation
3. PARTNER INFORMATION
4.SOCIAL HISTORY: housing, substance use, mental health,
4/4/2019 43BRIG HEMANT KUMAR

44. Providing PrEP
After confirmation of clinical eligibility:
Prescribe no more than 90-day supply of
PrEP
◦Truvada 1 tablet PO daily
(tenofovir 300mg + emtricitabine
200mg)
◦Insurance prior approval
◦Truvada for PrEP Medication Assistance
Program
4/4/2019 44BRIG HEMANT KUMAR

45. CONTD…..
3-month visit (1st )
HIV test
Assess for acute infection
Check for side effects
Pregnancy testing
Prescribe 90-day supply of medication
Every visit:
Assess adherence
Risk reduction
counseling
Provide condoms
4/4/2019 45BRIG HEMANT KUMAR

46. CONTD….
6-month
HIV test
STI test
Pregnancy test
Renal function
90 day prescription
9-month
HIV test
Pregnancy test
90 day
prescription
12-month
HIV test
STI tests
Pregnancy test
Renal function
90 day prescription
Assess the need to
continue PrEP
Every visit:
Assess adherence
Risk reduction counseling
Provide condoms
4/4/2019 46BRIG HEMANT KUMAR

47. 4/4/2019 BRIG HEMANT KUMAR 47
WHEN TO
PrEP ????

48. 1. Positive HIV result
2. Acute HIV signs or symptoms
3. Non-adherence
4. Renal disease
5. Changed life situation: lower
HIV risk
4/4/2019 48BRIG HEMANT KUMAR

49. On-Demand PrEP
IPERGAY:
◦ Randomized trial, 400 high-risk MSM
◦ peri-coital PrEP: (3 DOSE SCHEDULE )
Truvada 4 tablets 24 hours before sex, a
second dose 24 hours later, and a last one 24
hours later
◦86% reduction in HIV acquisition with on-
demand PrEP
◦ Intervention Préventive de l
4/4/2019 49BRIG HEMANT KUMAR

50. Future of PrEP
Cabotegravir: HIV integrase inhibitor
◦Can be administered orally or as
long-acting subcutaneous or
intramuscular injection
◦Single injection of long-acting
version could be effective for up to
3 months
4/4/2019 50BRIG HEMANT KUMAR

51. 4/4/2019 51BRIG HEMANT KUMAR

52. 4/4/2019 BRIG HEMANT KUMAR 52

53. REMEMBER …
4/4/2019 BRIG HEMANT KUMAR 53

54. 4/4/2019 BRIG HEMANT KUMAR 54

55. 4/4/2019 BRIG HEMANT KUMAR 55

56. 4/4/2019 BRIG HEMANT KUMAR 56