Pre-exposure Prophylaxis for HIV Prevention

Transcription

1 Mountain West AIDS Education and Training Center Pre-exposure Prophylaxis for HIV Prevention Concerns about PrEP: Sexual Behavior and STIs Joanne Stekler, MD MPH May 19, 2016 This presentation is intended for educational use only, and does not in any way constitute medical consultation or advice related to any specific patient.

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3 Topics To Be Covered Concerns about behavioral disinhibition (aka risk compensation) Sexual behavior in persons on PrEP STIs in persons on PrEP

4 Why is there concern about behavioral disinhibition? Risk compensation can negate prevention benefits of PrEP Our own morality/judgement (PrEP stigma) Important to remember: Birth control has not led to increased sexual risk Needle exchange has not led to increased IDU HPV vaccine has not led to earlier sexual debut

5 Behavioral disinhibition could change PrEP s clinical- and cost-effectiveness Chen & Dowdy, PLoS One, 2014; 9(10)

6 Behavioral disinhibition could change PrEP s clinical- and cost-effectiveness Chen & Dowdy, PLoS One, 2014; 9(10)

7 Behavioral disinhibition could change PrEP s clinical- and cost-effectiveness Chen & Dowdy, PLoS One, 2014; 9(10)

8 Proportion of HIV participants with any unprotected sex (%) PrEP and sexual behavior in RCTs In RCTs, condomless sex was less common over time. BUT subjects did not know if they were on PrEP or placebo. iprex Partners PrEP Follow-up time (Month) TDF FTC/TDF Placebo

9 PrEP and sexual behavior in Partners PrEP open-label extension No increase in condomless sex STIs pregnancy Average frequency of condomless sex Before after Mugwanya et al., Lancet Infect Dis, 2013

10 PrEP and sexual behavior in the real world

11 Behavior change and STIs in the Demo Project (San Francisco, Miami, Washington D.C.) Liu et al. JAMA Intern Med. 2016;176(1):75-84

12 STIs among PrEP users and persons at risk for HIV Kaiser-Permanente, CA, 12-month cumulative % N=657 PROUD Study, UK 12 months prior to enrollment N=544 60% 50% 40% 30% 30% 20% Z E R O 25% 20% 15% 10% 10% 5% 0% Any CT GC TP HIV 0% Rectal GC Rectal CT Urethral GC Urethral CT Syphilis Volk et al. Clin Infect Dis 2015 McCormack et al. Lancet 2016

13 Source: US Public Health Service. Clinical practice guidelines for PrEP. May 2014.

14 Summary of Recommended Laboratory Evaluation Baseline and Routine Monitoring for Patients taking PrEP Recommended Laboratory Testing and Frequency for Patients Taking PrEP Laboratory test Baseline Every 3 months At least every 6 months Notes HIV screening assay Consider need for HIV RNA PCR HBV antibody panel and HCV antibody Offer HBV vaccination if not immune Serum creatinine Avoid PrEP if CrCl <60 ml/min General STI screen Include oral/rectal screen for MSM if risk Pregnancy test for women Source: US Public Health Service. Clinical practice guidelines for PrEP. May 2014.

15 Recommended Follow-Up Counseling and Services Recommended Follow-Up Counseling and Services for Patients Taking PrEP Follow-up services Adherence counseling Behavioral risk reduction support and condoms Assessment for side effects Assessment for STI symptoms and symptoms of acute HIV For women, discuss pregnancy intent and contraceptive options Access to clean needles/syringes and drug treatment services Provide a refill of daily TDF/FTC for no more than 90 days Every 3 months Abbreviations: STI = sexually transmitted infection; TDF/FTC = tenofovir/emtricitabine Source: US Public Health Service. Clinical practice guidelines for PrEP. May 2014.

16 Frequent, asymptomatic STIs among persons on PrEP 100% Proportion of infections for which treatment would have been delayed with q6 month screening 90% 80% % 60% 50% 40% 30% % 10% 0% Gonorrhea n=181 Chlamydia n=210 Syphilis n=54 Total n=445 Detected Delayed Cohen et al, CROI 2016

17 Syphilis cases/year Incidence per 100,000 Syphilis in King County non-msm HIV- MSM HIV+ MSM Incidence (HIV+ MSM) Incidence (HIV- MSM)

18 Conclusions There is concern but currently no evidence of behavioral disinhibition (risk compensation) associated with PrEP use. PrEP is intended for people who, for whatever reason, cannot/will not/do not use condoms. PrEP decreases that person s risk for HIV acquisition (i.e. harm reduction). Frequent STI screenings are important in high-risk populations, whether or not persons are on PrEP.

19 Questions?