PREP CASES BREAKOUT CASE 1: COPING WITH PILL FATIGUE PE/LABS

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1 PREP CASES BREAKOUT CASE 1: COPING WITH PILL FATIGUE 28 year-old HIV-negative MSM CC: Rectal Mass and Diarrhea x 2 weeks PMH: No chronic medical issues - Diagnosed with secondary syphilis 9 months ago (RPR 1:512-> 1:4) - Rectal gonorrhea 3 months ago - Previously taking TDF/FTC for HIV prevention but stopped due to pill fatigue 3 months ago MATT SPINELLI, MD RESEARCH FELLOW, INFECTIOUS DISEASES DIVISION OF HIV, ID, AND GLOBAL MEDICINE SH: 3 Partners (receptive anal sex, inconsistent condom use) last month - Drugs: Meth and GHB occasional around the time of sex - Stably housed, lives alone PE/LABS Afebrile, 128/78 HR 88 Tired-appearing OP clear/no LAN Heart: No MRG/Lungs: CTAB/Abdomen: NTND No rash Rectal: 1-2cm mass palpated at rectal verge, tender to palpation 6.1 > 12.2 < 250 Creatinine 1.1 HIV Ag/Ab NR; RNA UD RPR 1:512->1:4 HCV NR HBV SAb+ Sag- Core- Dhawan et al. Ind. J. Path & Micro 2017

2 LYMPHOGRANULOMA VENEREUM PRESENTATION AND MANAGEMENT RECCS. Chlamydia serotypes L1-3 Primary stage (3-30 days) denoted by a small, painless ulcer 3-30 days postexposure WILL PREP WORK WITH SO MANY STIS? Strong evidence that PrEP is effective in the setting of STIs Syphilis incidence 7.2/100 PY in iprex-ole, did not differ between among those who did/did not elect to take PrEP; no difference in efficacy (Grant et al. Lancet ID 2014) Secondary stage (10-30 days after primary): tender inguinal and/or femoral lymphadenopathy (genital exposure), or hemorrhagic proctitis or proctocolitis (anal exposure) If confirmatory testing unavailable or high turnaround time, consider doxycycline x 21 days for rectal CT+ and proctitis SFDPH STD Control Health Alert 2004 Relationship between PrEP and risk behavior is inconclusive important to meet people where they are at A portion of increased STIs seen in PrEP users is a result of screening detecting asymptomatic infections (Traeger et al. AIDS 2018 #THAC0502) HIGH INCIDENCE OF HCV REINFECTION IN PREP USERS AMPrEP: PrEP Demo with 376 MSM and TGW in Amsterdam Tested every 6 months for HCV Incidence of primary infection: 1.0/100 py (95%CI ) (n=6) Incidence of re-infection: 25.5/100 py (95%CI ) (n=6) Number of cases WE NEED TO SCREEN OR STIS MAY INCREASE Male gonococcus cases in SF 1 Model of national GC/CT incidence per proportion screened over 6 month intervals 2 Hoornenborg et al. AIDS 2018 TUPDX SF HIV Epi Jenness et al. CROI 2017 #1034

3 IS HE A PREP CANDIDATE? RETENTION IN CARE: SOON TO BE MOST CRUCIAL ISSUE IN PREP IMPLEMENTATION 1 How do we address his pill fatigue? 38% on PrEP at review end Median time on PrEP: 8 months 1. Golub. Lancet HIV Spinelli et al. HIVR4P # OA TOP 5 REASONS WHY PEOPLE STOP PREP 1. Self-perceived low risk COPING WITH PILL FATIGUE Could on-demand PrEP (2-1-1) help with pill fatigue? 2. Cost or changes in coverage 3. Medication side effects (actual or anticipated) 4. Pill fatigue 5. Difficulty adhering to provider/lab appointments Buchbinder HIVR4P 2018 #SA16.2 Montreal cohort offered intermittent vs. daily PrEP Consistent use 34% for daily 43% for intermittent P=0.02 Greenwald et al, CROI 2018, #1038 Buchbinder HIVR4P 2018 #SA16.2

4 NO Endorsed HIV INFECTIONS by IAS-USA IN Guidelines: EITHER GROUP Saag et al. JAMA 2018 REAL WORD ON-DEMAND PREP SCENARIOS Treatment Follow-Up Pts-years HIV Incidence per 100 Pts-years (95% CI) TDF/FTC (Daily) (0-0.8) TDF/FTC (On Demand) (0-0.7) Mean follow-up: 7 months (SD: 4) 85 HIV-infections averted* * assuming an incidence of 9.17/100 PY as observed in the ANRS Ipergay study in Paris Molina et al. AIDS 2018 WEAE0406LB CASE 2: THREE-DRUG PREP? 39 y/o M with meth use disorder (injection) who has sex w/ M Interested in starting PrEP, uses shared injection equipment, 2 receptive CAI partners last month Lives in a shelter with difficulty remembering to take meds Endorses sore throat and chills, last sexual contact two weeks ago WHAT WOULD YOU DO NEXT? A) Repeat Ag/Ab, start PrEP if negative B) Obtain HIV viral load, start PrEP if negative C) Start PrEP today D) Start PrEP today, order HIV viral load just in case E) Start ART today, order HIV viral load Vitals/Exam unremarkable, OP clear, no rash Labs: HIV Ag/ab negative 5 days ago, Cr 0.9, HBV negative, HCV Ab +, HCV VL pending, STI testing pending

5 PHARYNGEAL GC+ Viral load returned <40 Received ceftriaxone and azithromycin Started PrEP within three days Visited Ward 86 pharmacy once a week to pick up HCV meds and pick up PrEP (concerns about theft at shelter) Vaccinated for HBV FOLLOW-UP VISIT Reported one month later to pharmacist -> he had been assaulted 4 days prior Thinks he was drugged at a Folsom Street party, woke up with needles in his arms Friend told him that he had sex with a person living with HIV Pharmacist reported he had not picked up PrEP for >1 week WHAT WOULD YOU DO NEXT? A) Reinitiate PrEP, he should be protected B) Hold PrEP, outside of the window for PEP, re-test within 2-4 weeks and reinitiate PrEP FOLLOW-UP Seen in urgent care, not started on PEP or restarted on PrEP due to being out of the PEP window Lost to follow-up C) Initiate DTG + TDF/FTC, plan to transition back to PrEP if HIV testing negative Returned two weeks later with subjective fever and sorethroat D) Initiate DTG + DRV/C + TDF/FTC, plan to transition back to PrEP if HIV testing negative

6 NOT AGAIN! WHAT WOULD YOU DO? A. Hold meds, if viral load detectable, initiate DTG+ TDF/FTC for likely acute infection B. Initiate DTG + TDF/FTC to treat likely ARS; continue indefinitely as testing could be unreliable C. Initiate DTG + TDF/FTC, stop dolutegravir if viral load undetectable and continue TDF/FTC for PrEP Started on DTG + TDF/FTC Viral load returned UD Dolutegravir stopped and continued PrEP once result returned TEACHING POINTS STIs are on the rise, seeing more unusual presentations of syphilis and remember LGV PrEP works in the settings of STIs; don t forget to screen Patients face barriers to adherence and retention in care; check in with your patients Intermittent PrEP is a good option for patients who can t take daily PrEP, particularly if they have infrequent sex Be vigilant for acute HIV in your PrEP patients, consider three or four drug therapy when in doubt, particularly if they remain at consistent risk of HIV