Getting PrEP to the patients who need it

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doi:doi: 10.12788/jfp.0686

Applied Evidence

Getting PrEP to the patients who need it

J Fam Pract. 2023 November;72(9):E1-E7 | doi: 10.12788/jfp.0686

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References

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7. Havens PL, Stephensen CB, Van Loan MD, et al. Decline in bone mass with tenofovir disoproxil fumarate/emtricitabine is associated with hormonal changes in the absence of renal impairment when used by HIV-uninfected adolescent boys and young men for HIV preexposure prophylaxis. Clin Infect Dis. 2017;64:317-325. doi: 10.1093/cid/ciw765

8. Pilkington V, Hill A, Hughes S, et al. How safe is TDF/FTC as PrEP? A systematic review and meta-analysis of the risk of adverse events in 13 randomised trials of PrEP. J Virus Erad. 2018;4:215-224.

9. Mayer KH, Molina JM, Thompson MA, et al. Emtricitabine and tenofovir alafenamide vs emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis (DISCOVER): primary results from a randomised, double-blind, multicentre, active-controlled, phase 3, non-inferiority trial. Lancet. 2020;396:239-254. doi: 10.1016/S0140-6736(20)31065-5

10. Liegeon G, Ghosn, J. Long-acting injectable cabotegravir for PrEP: a game-changer in HIV prevention. HIV Med. 2022;24:653-663. doi: 10.1111/hiv.13451

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13. Dimitrov D, Moore JR, Wood D, et al. Predicted effectiveness of daily and nondaily preexposure prophylaxis for men who have sex with men based on sex and pill-taking patterns from the Human Immuno Virus Prevention Trials Network 067/ADAPT Study. Clin Infect Dis. 2020;71:249-255. doi: 10.1093/cid/ciz799

14. Saag MS, Gandhi RT, Hoy JF, et al. Antiretroviral drugs for treatment and prevention of HIV infection in adults: 2020 recommendations of the International Antiviral Society-USA Panel. JAMA. 2020;324:1651-1669. doi: 10.1001/jama.2020.17025

15. Havens PL, Perumean-Chaney SE, Patki A, et al. Changes in bone mass after discontinuation of preexposure prophylaxis with tenofovir disoproxil fumarate/emtricitabine in young men who have sex with men: extension phase results of Adolescent Trials Network Protocols 110 and 113. Clin Infect Dis. 2020;70:687-691. doi: 10.1093/cid/ciz486

16. Neilan AM, Salvant Valentine S, Knopf AS. Case 27-2021: a 16-year-old boy seeking human immunodeficiency virus prophylaxis. N Engl J Med. 2021;385:1034-1041. doi: 10.1056/NEJMcpc1909626

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Data on the impact of Truvada for PrEP on fetal health are still emerging. A large study in Kenya showed no significant differences in preterm birth, low birth weight, or early infant growth, and a randomized, noninferiority trial in South Africa showed no association between Truvada for PrEP and preterm birth or the birth of small-for-gestational-age infants.^18,19 There are no definitive studies of breastfeeding infants exposed to Truvada, but data from previous trials of breastfeeding mothers who were taking the individual components that are combined in the Truvada pill indicated there is minimal medication exposure to the infant.⁵

PrEP studies in the peripartum period to date have been conducted exclusively among cisgender women, and data do not yet reflect the experiences of transgender men, genderqueer people, and nonbinary individuals in the peripartum period.⁵

Transgender people

Transgender women should be strongly considered candidates for PrEP as they are at an extremely high risk for HIV acquisition. The most recent National HIV Behavioral Surveillance survey found that approximately 42% of transgender women were living with HIV.²⁰ The survey revealed stark racial and ethnic disparities among transgender women living with HIV: 62% identified as Black/African American, compared with 35% Hispanic/Latina and 17% White.²⁰

Transgender women report high rates of sexual assault, unprotected receptive anal sex, commercial sex work, homelessness, mental health disorders, and substance use, putting them at increased risk for HIV acquisition.²¹ However, transgender women are less likely to have discussed PrEP with a clinician, are less likely to be on PrEP even when interested in starting, and have higher rates of medication nonadherence compared with cisgender MSM.^21,22 PrEP has not been found to decrease levels of feminizing hormones; however, studies are mixed as to whether feminizing hormones decrease Truvada concentrations in rectal mucosa, so clinicians should emphasize the importance of daily medication adherence.²³

Transgender men have not been included in any PrEP trials, so no specific recommendations are available.

Continue to: Disparities in PrEP access and use exist