‘PrEP in practice: Guidance for GPs’ (Duration: 40 to 60 minutes)
This online learning module provides guidance for general practitioners to better understand and safely prescribe PrEP. Note: If you a first-time user of the ASHM Learning Management System, you will first be directed to register as a new system user.
Access it here: https://lms.ashm.org.au/course/view.php?id=69
ASHM Australian HIV Pre-exposure Prophylaxis (PrEP) Clinical Guidelines have been published in the Journal of Virus Eradication (Journal of Virus Eradication 2017; 3: pp168–184) representing an adaptation and a revision of the 2014 United States Centers for Disease Control's PrEP guidelines. The 2017 Australian PrEP Guidelines have the benefits of having been being written and edited by clinicians, epidemiologists and representatives of peak Australian HIV community organisations who have significant experience of PrEP in the clinical, research and real-world settings. These guidelines are written for clinicians who will be initiating PrEP and monitoring people taking PrEP and are designed to reflect Australia’s unique epidemiology.
The recommendations included in the Guidelines are designed to:
Consumers in Australia can currently access PrEP through a number of mechanisms: They can purchase the drug without subsidy; import drugs into Australia for private use under the Personal Importation Scheme (and we know that a number of people are using this option); or seek enrolment in one of the current demonstration projects in Australia.
ASHM recommends that any individual considering PrEP discuss this with a clinician experienced in HIV management.
As of 6 May 2016 Truvada™ is licensed by the Therapeutic Goods Administration (TGA) for use as PrEP. Truvada™ is not currently subsidised by the Pharmaceutical Benefits Scheme (PBS) for preventative use. An application is underway for a PBS listing.
Although Truvada™ is not subsidised by the PBS for PrEP it can be prescribed off-label.
It is a pharmaceutical with potential side effects and care should be taken with its prescription. Consumers need to be aware that is being prescribed off-label; of the necessity to take the medication on a daily basis; the potential limitations if this dosing regimen is not maintained; and other preventative strategies to minimise the risk of exposure to HIV and other sexually transmissible (STI) and/or blood-borne infections. Furthermore, preliminary data from the Victorian PrEP Demonstration Project shows that at baseline 25 per cent of patients presenting for PrEP have an STI and one per cent are HIV seropositive. This highlights the need for clinical evaluation. Any patient who is on PrEP will need regular monitoring, prevention and adherence support, and will require maintenance prescriptions.
Evidence has been growing in support of the efficacy of PrEP. The key feature in preventing transmission is establishing and maintaining a therapeutic, preventative serum level of drugi . In late 2014, two trials stopped their placebo arms and offered all participants the active drug, given the differences which were observed between the active and control armsii , iii. While consumers and funders would like to know the least drug-heavy dose, adequate and simplified dosage is yet to be established and the optimum or minimum dosage and frequency is not yet determined. Long acting drugs which could be administered monthly or quarterly are being studied for both therapeutic and prophylactic applications.iv
Some patients are well informed about developments in HIV medicine and will actively seek out prophylaxis. Other patients may not have heard of PrEP, or may not feel comfortable asking you about it. PrEP is a significant commitment and should be restricted to individuals who are at elevated risk of HIV acquisition: Men who have unprotected sex with multiple partners; people who share injecting equipment; and patients in a relationship with a person with HIV who is not on treatment or who does not have an undetectable viral load1. Given the low prevalence of HIV in the community and the low but real risk of toxicity, daily PrEP should not be recommended for people at low risk. These patients should be counselled to use safer sex and safer injecting practices, but they should be encouraged to return to discuss PrEP if their situation changes and they become at high risk of acquiring HIV. Further guidance on how to establish a patient's level of HIV risk and eligibility for PrEP is provided in the Australian PrEP Guidelines.
Whether people are presenting for post-exposure prophylaxis (PEP) or pre-exposure prophylaxis (PrEP), it is essential to establish their current HIV status. This should be done using a conventional blood sample and laboratory testing. If the result is negative this should be confirmed by a repeat test in two or more weeks if there has been recent exposure to HIV. Any individual, no matter how informed they are, may have HIV infection when they present for PEP or PrEP. Experience from presentations for PEP revealed that 1.5-2.0 per cent of people in Australia who thought they were negative actually had established HIV infection at the time they sought PEP. Failure to establish a correct baseline of HIV status would erroneously suggest that PrEP had failed to protect the individual2.
In addition, if a person living with HIV fails to be diagnosed with HIV when they commence Truvada™ for PrEP or PEP there is a high likelihood that they will develop resistance to it as this medication alone is insufficient to treat HIV infection. This would then limit their future HIV treatment options.
Current scientific evidence shows that when Truvada™ is used for PrEP, it needs to be taken daily to provide effective coverage. The IPREX study demonstrates a linear correlation between the concentration of Truvada™ in the blood and its preventative efficacy. In short: If you don't take it, it doesn't work! Truvada™ combines tenofovir and emtricitabine and it appears both drugs are necessary to provide effective protection3 .
Patients should be counselled to continue using condoms and safe injecting practices. This will provide additional protection from the transmission of HIV and also prevent the acquisition of other sexually transmissible and blood-borne infections.
ASHM strongly advises monitoring any patient initiated or managed on PrEP. There is a risk of side effects - particularly renal complications - with Truvada™ so regular monitoring of renal function is necessary. In addition, patients receiving nephrotoxic agents may not be eligible to commence Truvada™. It is also important to regularly test patients for HIV and other sexually transmissible and blood-borne infections. This will also provide an opportunity to discuss the continued need for PrEP. The Australian Guidelines on the prescription of PrEP guide the periodicity of clinical review and the online 2015 ASHM HIV Management contains detailed information about PrEP. Given that Truvada™ PrEP is being prescribed off-label, it is important that the prescriber understands their responsibilities and gains informed consent from the patient.
While PrEP is effective if taken at a therapeutic level, the importance of establishing and maintaining this cannot be over emphasised and individuals taking PrEP need to be fully appraised of this. Intermittent PrEP has the combined risk of facilitating HIV acquisition; removing tenofovir and emtricitabine from the treatment drugs available should HIV be acquired; and transmitting tenofovir and/or emtricitabine resistance. If a patient on Truvada™ PrEP does acquire HIV s/he will need to take additional drugs to treat HIV.
PrEP should be used whilst the person remains at high risk of acquiring HIV infection. Current PrEP requires consistent usage, to establish an effective drug level to provide protection against the acquisition of HIV. IT IS NOT A MORNING AFTER PILL, NOR IS IT A ONE PILL BEFORE EXPOSURE PILL. Long-lasting injectable agents and possibly drug implants are being researched for their efficacy in preventing HIV infectionv, but they are not available yet.
We do not have a lot of experience in the long-term use of PrEP. It is expected that Truvada™ PrEP will be an option that people use for a period of time, and in the event that long-term injectable or slow release preparations are effective they will replace daily oral regimens. Ultimately, we hope that a vaccine will replace PrEP. In the interim, Truvada™ can provide an effective preventative.
The most likely negative sequelae of long-term PrEP are likely to be the development of resistance and, in a small number of people, the development of renal toxicity and loss of bone mineral density. If patients are not adherent to PrEP they should be counselled to stop taking it. Likewise, if renal toxicity cannot be managed PrEP should be stopped.
PrEP cannot currently be accessed through the PBS as Truvada™. An application has been submitted to the Pharmaceutical Benefits Advisory Committee (PBAC) to get subsidy through the PBS.
Truvada™ can be prescribed and purchased without subsidy at a cost in the vicinity of $850 per bottle of 30 pills. Patients can also personally import the drug in person or via mail. Details of how to do this can be obtained on the TGA website.
Generic drugs can be purchased via a number of websites. These drugs have not been evaluated by the TGA, but Truvada™ has been evaluated by the US regulator, the FDA. Generic tenofovir and emtricitabine (combined in a single tablet) will cost in the vicinity of $130 per month or $330 for a three month supply. Generic drugs use alternative trade names and packaging and may be a different colour or shape so you must be sure that the drug being purchased is the correct formulation. ACON has simple step-by-step instructions on their website on how to access PrEP using the personal importation scheme.
Self-importation has some risks associated with it. You do not have the quality protection provided by drugs evaluated and listed on the ARTG. You need to be careful about the veracity of the website. Supply time may vary and the postage time could be delayed if customs investigates the package. Self-importation is legal, but not routine. Having a valid Australian prescription, completed by a registered medical practitioner and completing all the paper work will facilitate the process but patients should allow up to eight weeks for delivery.
The first PrEP study in Australia, VicPrEP, led by A/Prof Edwina Wright in Melbourne, is now full (for more information see www.vicprep.csrh.org). A large PrEP demonstration study, EPIC NSW run by the Kirby Institute, is currently enrolling 3700 participants in NSW and is designed to provide access to PrEP (for more information see http://epic-nswstudy.org.au). A study led by A/Prof Darren Russell commenced recruitment in Queensland in April 2015 (for more information see www.hivfoundation.org.au)
The website http://www.aids-drugs-online.com/ is a source for low-cost generic versions of HIV medications from various overseas manufacturers. Other suppliers can be found by typing "aids drugs online" into your search engine. Please be aware that the brand names used on AIDS Drugs Online are not the same as the brands in Australia:
a. Australian brand name: Truvada
b. AIDS Drugs Online (ADO) brand name: Tenvir EM
Once you have obtained your prescription for Truvada™ (Tenvir EM) from your doctor, take the following steps to order Tenvir EM online.
PrEP is a preventative method by which an individual takes a dose of antiretrovirals before a possible risk exposure to reduce their risk of acquiring HIV infection.
PrEP is currently not approved by the Therapeutic Goods Administration (TGA) or listed under the PBS. Pilot studies are being conducted in Brisbane, Melbourne and Sydney to evaluate PrEP in the Australian context.
ASHM, through the Antiretroviral Guidance Committee (ARVG), has worked closely with the demonstration projects to develop an Australian Commentary on the USA CDC PrEP Guidelines.
Visit ACON http://endinghiv.org.au
Visit Queensland HIV Foundation www.hivfoundation.org.au