HIV Testing, PrEP, and PEP Overview

Overview of HIV Testing

• HIV testing is a quality measure in clinical practice.

  • Recommendation: Every individual should have an HIV test at least once during their lifetime.

  • Clinics are graded based on whether their patients have been tested.

Importance of Screening

• Increased emphasis on screening all individuals, not just those who are aware of their risk factors.

  • Approximately 13% of people with HIV in the United States are unaware of their status.

  • Early identification of HIV-positive individuals allows for early access to antiretroviral therapy (ART).

  • Benefits:

    • Reduces advanced immunocompromise.

    • Decreases transmission of HIV to others.

  • Patients treated before developing advanced immunosuppression can expect life expectancy on par with the general population.

Target Populations for Screening

• All individuals should be screened at least once.

• High-risk populations who may require more frequent testing include:

  • Individuals presenting with clinical manifestations of acute HIV infection.

  • Those who have confirmed exposure to HIV.

  • Men and transgender women engaging in anal sex without condoms.

  • Persons who inject drugs or exchange sex for drugs/money.

  • Individuals from regions with significant HIV epidemics (e.g., Africa).

  • Patients presenting for STI screenings or who have tested positive for STIs or Hepatitis B/C.

Testing Methodologies

• Recommended testing method: Fourth-generation combination HIV-1 and HIV-2 immunoassay.

  • If positive, confirm with HIV-1 and HIV-2 antibody differentiation test.

  • This helps in determining which type of HIV is present, guiding treatment strategies.

• Rapid point-of-care tests (e.g., fingerstick tests).

  • Preliminary results; positive tests must be confirmed through lab testing.

  • Negative results are considered satisfactory temporarily.

Follow-Up Tests for HIV Positive Patients

• Recommended additional lab tests following a positive HIV test:

  • Check viral load and CD4 cell count.

  • CD4 count < 200 requires attention to opportunistic infections and prophylaxis.

  • CBC to check for potential blood issues (anemia, leukopenia, lymphopenia, thrombocytopenia).

  • Creatinine and creatinine clearance for renal function assessment.

  • Liver function tests (LFTs) and bilirubin.

  • Baseline glucose and lipid profile to assess cardiac risk.

  • Pregnancy test for all women of childbearing age.

  • Screen for hepatitis A, B, and C, as well as tuberculosis and other STIs.

  • Cervical and anal cancer screenings due to higher rates in immunocompromised individuals.

Immediate Treatment Recommendations

• Initiate antiretroviral therapy (ART) immediately upon diagnosis.

• Consider prophylaxis for opportunistic infections for CD4 counts below 200.

• Counsel patients on risk reduction strategies.

Treatment Specializations and Referrals

• General family practitioners may not start ART without specific training.

  • Specialist referrals are often necessary for HIV treatment (e.g., infectious disease specialists).

• Primary care providers still manage overall patient health, including regular exams and screenings.

Pre-Exposure Prophylaxis (PrEP)

• Target population: HIV-negative individuals at high risk of HIV infection, with normal kidney function and commitment to adherence.

• Efficacy: PrEP can reduce the risk of acquiring HIV by up to 99% among adherent individuals.

• Recommended monitoring includes STI testing and renal function checks (creatinine).

• Areas of concern during contact: oral, vaginal, urethral, and rectal infections.

High-Risk Populations for PrEP

• Men and transgender women engaging in anal sex without condoms.

• Heterosexual individuals with high-risk partners (e.g., partners who have multiple sexual partners or use injection drugs).

• Individuals who inject drugs or have had another STI within the last 12 months.

PrEP Regimens Available

1. TDF/FTC (Truvada)

   • Most well-studied and commonly used.

   • Recommended for all populations including pregnant women.

   • Side effects: possible decrease in kidney function and bone density; monitor creatinine.

2. TAF/FTC (Descovy)

   • Newer agent; better renal profile than Truvada.

   • Potential side effects: mild increases in triglycerides and weight. Limited studies on cisgender women and injection drug users.

3. Injectable PrEP (Apretude)

   • Administered every other month.

   • Suitable for those with reduced kidney function; lack of studies in certain populations.

Monitoring and Follow-Up for PrEP Patients

• Regular follow-up every three months is critical:

  • HIV testing.

  • STI testing as applicable for oral, vaginal, urethral, and rectal areas.

  • Assess renal function and monitor lipid panels.

  • Monitor for risks related to pregnancy.

Management of Hepatitis B in PrEP Patients

• Hepatitis B co-infection can complicate PrEP and treatment; must be screened and managed appropriately.

New STI Prophylaxis Guidelines (DoxyPep)

• June 2024 CDC guidelines recommend DoxyPep as post-exposure prophylaxis for certain groups at high risk for STIs.

  • Target group: MSM and transgender women at risk or with previous STIs in the last year.

  • Dosage: 200 mg within 72 hours of unprotected sex.

  • Effectiveness: Shown to reduce syphilis, chlamydia, and gonorrhea incidence.

• Concerns: Long-term effects on antibiotic resistance are still uncertain; shared decision making is encouraged for determining eligibility, especially for cisgender women.

Conclusion

• Continuous communication with patients regarding their risks and the importance of testing and preventive measures.

• Stay updated on guidelines and adaptations in the field of HIV and STI treatments.