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Implementing PrEP to Decrease HIV Transmission Rates Among Females

Published:December 18, 2021DOI:https://doi.org/10.1016/j.nurpra.2021.11.021

      Highlights

      • The leading cause of HIV transmission for persons assigned female at birth is penis-to-vaginal intercourse.
      • Providers who follow clinical practice guidelines for prescribing and monitoring PrEP will have the appropriate tools to implement this therapy into their practice.
      • The promotion and utilization of PrEP will lead to decreases in new HIV cases.

      Abstract

      In 2018, 5.1 per 100,000 persons in the United States assigned females at birth (AFAB) were living with human immunodeficiency virus (HIV). HIV prevention tools, including daily oral pre-exposure prophylaxis (PrEP), screening for sexually transmitted infections, treatment, and sexual health counseling, can be implemented into clinical practice to address the prevalence of HIV infection among this population. Historically, this population has had a decreased opportunity to be screened for HIV or offered PrEP to protect them from HIV. Providers can incorporate PrEP as a standard preventative option in their practice for persons AFAB.

      Keywords

      In 2018, 5.1 per 100,000 persons in the United States assigned female at birth (AFAB) were living with human immunodeficiency virus (HIV). HIV prevention tools, including daily oral preexposure prophylaxis (PrEP), screening for sexually transmitted infections (STIs), and treatment and sexual health counseling, can be utilized to address the prevalence of HIV infection among this population.
      • Hodges-Mameletzis I.
      • Fonner V.A.
      • Dalal S.
      • Mugo N.
      • Msimanga-Radebe B.
      • Baggaley R.
      Pre-exposure prophylaxis for HIV prevention in women: current status and future directions.
      According to the Centers for Disease Control and Prevention (CDC), 58% of AFAB individuals living with HIV were Black/African American, 21% were White, and 17% were Hispanic/Latinx, with the leading method of transmission being penis-to-vagina sexual contact.

      Centers for Disease Control and Prevention. HIV surveillance report, 2018. Vol. 31. Updated 2020.

      In some cases, members of this population might not be aware of the HIV status of their partners, if their partners are correctly taking antiretroviral therapy (ART), if their HIV+ partners have achieved viral suppression for at least 6 months, or if their partners engage in behaviors that increase their HIV risk.
      • Bradley E.L.
      • Hoover K.W.
      Improving HIV preexposure prophylaxis implementation for women: summary of key findings from a discussion series with women’s HIV prevention experts.
      ,
      • Sionean C.
      • Le B.C.
      • Hageman K.
      • et al.
      HIV Risk, prevention, and testing behaviors among heterosexuals at increased risk for HIV infection—National HIV Behavioral Surveillance System, 21 US cities, 2010.

      Background

      AFAB individuals are often offered screening for STIs, such as chlamydia and gonorrhea, during routine and annual examinations but typically are not offered HIV screening in the same manner.
      • Lockwood C.J.
      Key points for today’s well-woman’ exam: a guide for ob/gyns.
      ,
      • Seidman D.
      • Carlson K.
      • Weber S.
      • Witt J.
      • Kelly P.J.
      United States family planning providers’ knowledge of and attitudes towards preexposure prophylaxis for HIV prevention: a national survey.
      In one study, female adolescents and young adults were more likely to consent to HIV screening if offered rather than to initiate the request, especially if the results were immediately available.
      • Buzi R.S.
      • Madanay F.L.
      • Smith P.B.
      Integrating routine HIV testing into family planning clinics that treat adolescents and young adults.
      Additional studies have demonstrated that these individuals, regardless of age, have fewer opportunities to be offered an HIV screening or discuss utilizing PrEP to protect them from HIV infection.
      • Patel D.
      • Johnson C.H.
      • Krueger A.
      • et al.
      Trends in HIV testing among US adults, aged 18–64 years, 2011–2017.
      ,
      • Yumori C.
      • Zucker J.
      • Theodore D.
      • et al.
      Women are less likely to be tested for hiv or offered preexposure prophylaxis at the time of sexually transmitted infection diagnosis.
      Race has also determined fewer opportunities for PrEP for persons AFAB. Black individuals are 17 times and Hispanic/Latinx individuals are 4 times more likely to become diagnosed with HIV in their lifetime compared with White AFAB individuals.
      • Calabrese S.K.
      • Dovidio J.F.
      • Tekeste M.
      • et al.
      HIV pre-exposure prophylaxis stigma as a multidimensional barrier to uptake among women who attend planned parenthood.
      ,
      • Jackson-Gibson M.
      • Ezema A.U.
      • Orero W.
      • et al.
      Facilitators and barriers to HIV pre-exposure prophylaxis (PrEP) uptake through a community-based intervention strategy among adolescent girls and young women in Seme Sub-County, Kisumu, Kenya.
      In 2018, there were 14,770 PrEP prescriptions written, despite there being 225,573 females who met the indications for PrEP.
      Centers for Disease Control and Prevention
      Core indicators for monitoring the Ending the HIV Epidemic initiative: HIV diagnoses and linkage to HIV medical care, 2019 (preliminary data, reported through December 2019); pre-exposure prophylaxis (PrEP)—2018, updated. HIV Surveillance Data Tables web site. Published 2020. Updated August 2020.
      A common barrier to access for HIV screening and appropriate linkage to care may be providers’ discomfort due to inexperience.
      • Leblanc N.M.
      • Flores D.D.
      • Barroso J.
      Facilitators and barriers to HIV screening: a qualitative meta-synthesis.
      • Williford S.L.
      • Humes E.
      • Greenbaum A.
      • Schumacher C.M.
      HIV screening among gonorrhea-diagnosed individuals; Baltimore, Maryland; April 2015 to April 2019.
      • Rodriguez V.
      • Lester D.
      • Connelly-Flores A.
      • Barsanti F.A.
      • Hernandez P.
      Integrating routine HIV screening in the New York City community health center collaborative.
      Through educational opportunities, providers can acquire the knowledge necessary to reduce these barriers to care and promote a safe, culturally competent environment for people, regardless of sex assigned at birth, sexual orientation, gender identity, or expression.
      • Waryold J.M.
      • Kornahrens A.
      Decreasing barriers to sexual health in the lesbian, gay, bisexual, transgender, and queer community.

      Screening opportunities for HIV

      Providing access to HIV testing and linkage to care promptly improves health outcomes. The CDC recommends routine HIV screening in health care settings for persons aged 13–64 years and at least annual screening for persons at a higher risk of infection.
      • Dailey A.F.
      • Hoots B.E.
      • Hall H.I.
      • et al.
      Vital signs: human immunodeficiency virus testing and diagnosis delays—United States.
      Table 1 further describes the criteria for which more frequent screening is recommended.
      American College of Obstetricians and Gynecologists
      ACOG Committee Opinion No 596: routine human immunodeficiency virus screening.
      • Owens D.K.
      • Davidson K.W.
      • Krist A.H.
      • et al.
      Screening for HIV infection: US preventive services task force recommendation statement.
      • Chou R.
      • Dana T.
      • Grusing S.
      • Bougatsos C.
      Screening for HIV infection in asymptomatic, nonpregnant adolescents and adults: a systematic review for the US Preventive Services Task Force.
      In addition to these recommendations, the American College of Obstetricians and Gynecologists (ACOG) strongly suggests that individuals who wish to become pregnant or are currently pregnant be offered an HIV test. Early detection for HIV, with linkage to early ART, reduces viral transmission to the unborn child. With an estimated 8,700 individuals living with HIV giving birth each year in the United States, the incidence of perinatal HIV infection has significantly declined primarily because of routine prenatal HIV screening and ART.
      Department of Health and Human Services
      Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. Published 2019. Updated Feb. 10, 2021.
      ,
      Centers for Disease Control and Prevention
      State laws that address high-impact HIV Prevention Efforts. Published 2020. Updated August 28, 2020.
      Although HIV screening during pregnancy is strongly supported by ACOG and the CDC,
      Centers for Disease Control and Prevention
      State laws that address high-impact HIV Prevention Efforts. Published 2020. Updated August 28, 2020.
      ,
      American College of Obstetricians and Gynecologists. ACOG Committee Opinion No
      752: Prenatal and perinatal human immunodeficiency virus testing.
      20 states have no statutes mandating it.
      Centers for Disease Control and Prevention
      Perinatal HIV Testing Laws. Published 2020. Updated May 12, 2020.
      Routine screening is instrumental in detecting HIV early, limiting HIV-related illnesses, and providing linkage to care for ART, and it is known to improve health outcomes. Approximately 40% of HIV transmissions occur by those unaware of their positive statuses.
      • Dailey A.F.
      • Hoots B.E.
      • Hall H.I.
      • et al.
      Vital signs: human immunodeficiency virus testing and diagnosis delays—United States.
      Table 1Screening Assigned Females at Birth Annually Due to Increased Risk to Human Immunodeficiency Virus (HIV)
      • Have had more than 1 sexual partner (either oral, vaginal, or anal) since their last HIV test
      • Have had a sexual encounter with a man who has sex with men
      • Have had a sexual encounter with another person without a condom/barrier
      • Have engaged in sex for drugs or money
      • Is currently or has been with a person who injects drugs
      • Are sex partners of HIV-infected persons
      • Has had treatment for a sexually transmitted infection
      Sources: American College of Obstetricians and Gynecologists,
      American College of Obstetricians and Gynecologists
      ACOG Committee Opinion No 596: routine human immunodeficiency virus screening.
      Owens et al,
      • Owens D.K.
      • Davidson K.W.
      • Krist A.H.
      • et al.
      Screening for HIV infection: US preventive services task force recommendation statement.
      and Chou et al.
      • Chou R.
      • Dana T.
      • Grusing S.
      • Bougatsos C.
      Screening for HIV infection in asymptomatic, nonpregnant adolescents and adults: a systematic review for the US Preventive Services Task Force.

      Barriers Affecting AFAB

      Gender disparities in HIV and STI screens have led to missed opportunities for providers to offer HIV prevention services. AFAB are less likely to obtain the same opportunities as their counterparts assigned male at birth (AMAB).
      • Tekeste M.
      • Hull S.
      • Dovidio J.F.
      • et al.
      Differences in medical mistrust between Black and White women: implications for patient–provider communication about PrEP.
      AFAB are routinely not educated about PrEP, creating a significant barrier for self-referral programs. In some cases, based on AFAB sexual practices, they are perceived to be low risk for HIV acquisition.
      • Yumori C.
      • Zucker J.
      • Theodore D.
      • et al.
      Women are less likely to be tested for hiv or offered preexposure prophylaxis at the time of sexually transmitted infection diagnosis.
      ,
      • Aaron E.
      • Blum C.
      • Seidman D.
      • et al.
      Optimizing delivery of HIV preexposure prophylaxis for women in the United States.
      ,
      • Bailey J.L.
      • Molino S.T.
      • Vega A.D.
      • Badowski M.
      A review of HIV pre-exposure prophylaxis: the female perspective.
      This perception is challenged given that AFAB aged 15-24 are at higher risk of HIV acquisition compared to individuals AMAB of the same age worldwide.
      • Bailey J.L.
      • Molino S.T.
      • Vega A.D.
      • Badowski M.
      A review of HIV pre-exposure prophylaxis: the female perspective.
      This is in addition to AFAB being less likely than their counterparts to know their partner’s HIV status.
      • Aaron E.
      • Blum C.
      • Seidman D.
      • et al.
      Optimizing delivery of HIV preexposure prophylaxis for women in the United States.
      Provider bias is another barrier faced by AFAB.
      • Yumori C.
      • Zucker J.
      • Theodore D.
      • et al.
      Women are less likely to be tested for hiv or offered preexposure prophylaxis at the time of sexually transmitted infection diagnosis.
      AFAB experience barriers from providers that include lack of opportunity to discuss sexual activity outside of utilizing barriers and contraception, a fear of judgment from their provider’s, the provider’s comfort in discussing PrEP, and perceived and actual risk of HIV acquisition.
      • Calabrese S.K.
      • Dovidio J.F.
      • Tekeste M.
      • et al.
      HIV pre-exposure prophylaxis stigma as a multidimensional barrier to uptake among women who attend planned parenthood.
      ,
      • Tekeste M.
      • Hull S.
      • Dovidio J.F.
      • et al.
      Differences in medical mistrust between Black and White women: implications for patient–provider communication about PrEP.
      ,
      • Nydegger L.A.
      • Dickson-Gomez J.
      • Ko T.K.
      Structural and syndemic barriers to PrEP adoption among Black women at high risk for HIV: a qualitative exploration.
      ,
      • Kingsberg S.A.
      • Schaffir J.
      • Faught B.M.
      • et al.
      Female sexual health: barriers to optimal outcomes and a roadmap for improved patient–clinician communications.
      Providers can assist with overcoming this barrier by counseling patients about PrEP services during routine visits. Providers can further reduce these barriers by establishing communication in which concerns can be expressed without fear of judgment.
      • Buchbinder S.P.
      Maximizing the benefits of HIV preexposure prophylaxis.
      When providing counseling, AFAB will benefit from receiving information on the diagnosis, prevention, screening, and treatment of STIs and HIV.
      • Frati E.R.
      • Fasoli E.
      • Martinelli M.
      • et al.
      Sexually transmitted infections: a novel screening strategy for improving women’s health in vulnerable populations.
      Because discussing sexual health can be difficult for even the most experienced providers, creating an environment conducive to open, fluid communication will enable patients to express sexual perspectives and concerns. Before engaging in any discussion during a visit, providers are encouraged to ensure that interruptions will be limited and that the individual is appropriately dressed. If the patient presents a complaint that may be related to an STI, they may already have feelings of apprehension or concern about being judged by the provider. The provider can compensate for these feelings by avoiding assumptions, using culturally competent terminology, and treating the individual with an understanding approach.
      • Waryold J.M.
      • Kornahrens A.
      Decreasing barriers to sexual health in the lesbian, gay, bisexual, transgender, and queer community.
      ,
      • Kingsberg S.A.
      • Schaffir J.
      • Faught B.M.
      • et al.
      Female sexual health: barriers to optimal outcomes and a roadmap for improved patient–clinician communications.
      After establishing the provider–patient relationship, providers individualize their care based on their health needs and goals, including pregnancy and family planning. If pregnancy is intended, consultation with an expert clinician is needed to ensure safety for both the person and the unborn child. AFAB having sexual relations with HIV-discordant persons may become interested in taking PrEP while pregnant or trying to conceive if their partners are not taking antiretroviral medication or if they are not virologically suppressed. PrEP may be used in pregnancy; however, providers are encouraged to consult or refer patients to an experienced prescriber.
      Centers for Disease Control and Prevention
      Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 Update: a clinical practice guideline. March 2018.
      As providers embrace cultural humility and recognize one’s gender identity and expression may differ from the sex assigned at birth, AFAB who do not identify as cisgender women may not feel comfortable discussing sexual health concerns with providers. Providers can overcome this barrier by asking patients their pronouns and incorporating inclusive language during visits. When discussing sexual activity, providers are encouraged to utilize biological body terms, such as vagina-to-penis, instead of male and female sexual intercourse,
      • Waryold J.M.
      • Kornahrens A.
      Decreasing barriers to sexual health in the lesbian, gay, bisexual, transgender, and queer community.
      thus providing culturally tailored care for the individual. Table 2 shows resources that a provider can use to help establish a supportive approach. Irrespective of the reason for the visit, the person should be made aware that screening for HIV is a routine part of their overall health assessment. This communication allows the provider to correct misconceptions, thus providing an opportunity to offer HIV screening and discuss prevention, thereby limiting the spread of HIV and associated morbidity and mortality.
      Table 2Resources for Discussing Sexual Health and Screening for Sexually Transmitted Infections

      Prevention Strategies

      Before initializing PrEP, counseling provided with the AFAB should include intent to conceive and prevention of STIs, including HIV. In one study, AFAB who rely on nonbarrier contraception use, such as oral contraception, were less likely to incorporate condom use, increasing their risk of STI and HIV acquisition.
      • Hynes J.S.
      • Sales J.M.
      • Sheth A.N.
      • Lathrop E.
      • Haddad L.B.
      Interest in multipurpose prevention technologies to prevent HIV/STIs and unintended pregnancy among young women in the United States.
      Discussing other forms for barrier contraception such as dental dams and gloves gives the person additional options to make informed decisions regarding their sexual practices.
      • Jahn J.L.
      • Bishop R.A.
      • Tan A.S.
      • Agénor M.
      Patient–provider sexually transmitted infection prevention communication among young adult sexual minority cisgender women and nonbinary assigned female at birth individuals.
      Recommendations from the CDC and ACOG strongly support offering PrEP to persons at high risk for HIV transmission.
      • Owens D.K.
      • Davidson K.W.
      • Krist A.H.
      • et al.
      Screening for HIV infection: US preventive services task force recommendation statement.
      ,
      • Kourtis A.
      • Read J.
      • Jamieson D.
      ACOG Committee Opinion No
      595: Committee on Gynecologic Practice: preexposure prophylaxis for the prevention of human immunodeficiency virus.
      In conjunction with screening for HIV, a discussion of using PrEP and ways to minimize risks are provided. For AFAB who have an increased risk of becoming infected with HIV, PrEP is an appropriate prevention strategy in addition to other risk reduction techniques. The food and drug administration (FDA) approved option for PrEP in AFAB is a fixed dose of tenofovir disoproxil fumarate 300 mg/emtricitabine 200 mg (TDF/FTC). TDF/FTC inhibits a process called reverse transcriptase by preventing the conversion of HIV RNA into HIV DNA, which will slow and prevent viral replication.
      • Hodges-Mameletzis I.
      • Fonner V.A.
      • Dalal S.
      • Mugo N.
      • Msimanga-Radebe B.
      • Baggaley R.
      Pre-exposure prophylaxis for HIV prevention in women: current status and future directions.
      • Yap P.K.
      • Loo Xin G.L.
      • Tan Y.Y.
      • et al.
      Antiretroviral agents in pre-exposure prophylaxis: emerging and advanced trends in HIV prevention.
      To obtain adequate protection and reach maximum concentration in the blood and cervicovaginal tissue, it needs to be taken daily for at least 20 days.
      • Yap P.K.
      • Loo Xin G.L.
      • Tan Y.Y.
      • et al.
      Antiretroviral agents in pre-exposure prophylaxis: emerging and advanced trends in HIV prevention.
      AFAB who engage in receptive anal sex receive maximum concentration in rectal tissues after 7 days of continuous TDF/FTC. This is due to its long intracellular half-life and high concentrations in rectal tissue.
      • Buchbinder S.P.
      Maximizing the benefits of HIV preexposure prophylaxis.
      ,
      • Yap P.K.
      • Loo Xin G.L.
      • Tan Y.Y.
      • et al.
      Antiretroviral agents in pre-exposure prophylaxis: emerging and advanced trends in HIV prevention.
      Although not FDA approved, trials have shown that TDF alone demonstrated efficacy and safety when combined with barrier contraception use, diagnosis and treatment of sexually transmitted infection, and sexual risk reduction counseling. TDF alone was proven effective for high-risk people that engage in sexual activity that includes penis-to-vagina contact and persons who inject drugs.
      • Yap P.K.
      • Loo Xin G.L.
      • Tan Y.Y.
      • et al.
      Antiretroviral agents in pre-exposure prophylaxis: emerging and advanced trends in HIV prevention.
      ,
      • Pilkington V.
      • Hill A.
      • Hughes S.
      • Nwokolo N.
      • Pozniak A.
      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.
      Before initiating a TDF/FTC regimen, side effects to be discussed are headaches, flatulence, and nausea. These side effects are usually transient and will generally resolve after the first month. Providers can discuss using over-the-counter medications to manage these side effects. It is also important to discuss potential drug interactions. Interaction with other antivirals, such as valacyclovir for herpes simplex virus and nonsteroidal antiinflammatory drugs, may reduce renal function. TDF/FTC, however, does not negatively interact with oral contraception.
      Centers for Disease Control and Prevention
      Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 Update: a clinical practice guideline. March 2018.
      Providers should also discuss with the patient the possibility of an increased risk of osteoporosis and renal toxicity observed in antiretroviral regimens containing TDF. When evaluating for potential adverse effects, routine laboratory testing will be needed while taking TDF/FTC for PrEP. Providers should also note that a baseline or routine bone density exam is not recommended for the sole purpose of evaluating TDF/FTC’s effect on bone density. Although these adverse reactions have been demonstrated in a small number of people taking TDF/FTC, clinical trials have shown that these effects are not statistically significant because the benefits outweigh the risks of HIV infection.
      • Bradley E.L.
      • Hoover K.W.
      Improving HIV preexposure prophylaxis implementation for women: summary of key findings from a discussion series with women’s HIV prevention experts.
      ,
      Centers for Disease Control and Prevention
      Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 Update: a clinical practice guideline. March 2018.
      There continues to be research on and development of other PrEP alternatives for AFAB, although the US FDA has not approved these. One such development is tenofovir alafenamide 25 mg/emtricitabine 200 mg (TAF/FTC) for AFAB. TAF/FTC has been approved for PrEP for cisgender men and transgender women since 2019; however, because AFAB had been excluded from the study, providers are unable to prescribe it for this population. Further use of TAF/FTC in females is currently under investigation.
      • Hodges-Mameletzis I.
      • Fonner V.A.
      • Dalal S.
      • Mugo N.
      • Msimanga-Radebe B.
      • Baggaley R.
      Pre-exposure prophylaxis for HIV prevention in women: current status and future directions.
      An additional PrEP option that is not in a daily oral tablet form is the dapivirine vaginal ring. This ring is placed in the vagina, changed every 28 days, and provides similar protection compared with the oral ARTs used for PrEP. Although not approved by the FDA, this method does have the endorsement of the World Health Organization.
      • Glaubius R.
      • Ding Y.
      • Penrose K.J.
      • et al.
      Dapivirine vaginal ring for HIV prevention: modelling health outcomes, drug resistance and cost-effectiveness.
      Another nonoral treatment being considered is the long-acting injectable agent cabotegravir as an option for PrEP. This product would provide convenience for people who are not interested in taking medication daily and may increase adherence.
      • Kerrigan D.
      • Mantsios A.
      • Grant R.
      • et al.
      Expanding the menu of HIV prevention options: a qualitative study of experiences with long-acting injectable cabotegravir as PrEP in the context of a phase II trial in the United States.
      Similar to obtaining a meaningful, culturally competent sexual history, providers may struggle or be unable to prescribe PrEP for their patients at high risk for HIV. These providers and patients can be referred to a web-based national directory of PrEP providers. These providers have self-identified as able and willing to prescribe, initiate, and continue PrEP. The website (https://preplocator.org/), initially created by Dr. Aaron Siegler at Emory University in 2016, is now supported by the CDC’s National Prevention Information Network. It is a national, comprehensive directory of public and private PrEP providers located within the United States.
      • Siegler A.J.
      • Wirtz S.
      • Weber S.
      • Sullivan P.S.
      Developing a web-based geolocated directory of HIV pre-exposure prophylaxis-providing clinics: the PrEP locator protocol and operating procedures.
      Interested providers are able to self-identify and enroll via the website.
      All persons, regardless of gender identity, sexual orientation, or expression, who have an incident of substantial risk for HIV exposure must receive antiviral treatment to help prevent transmission if taken within 24 to 36 hours, but no longer than 72 hours from exposure.
      • Dominguez K.L.
      • Smith D.K.
      • Thomas V.
      • et al.
      Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV—United States, 2016.
      Nonoccupational postexposure prophylaxis (nPEP) is recommended for individuals who have been exposed to HIV outside their employment. A 28-day course of nPEP, consisting of a 3-drug antiretroviral regimen, is taken daily to help reduce HIV transmissions. Additional testing may be needed depending on the nature of the exposure, such as screening for exposure to STIs. Persons who have been the victim of a sexual assault may need to be referred to a designated exam facility for victim-centered care.
      US Department of Justice
      A national protocol for sexual assault medical forensic examinations: adults/adolescents (NCJ 228119). 2nd ed. April 2013.
      In cases not involving an assault, providing nPEP allows the provider to introduce PrEP to patients who anticipate an ongoing risk or have requested multiple courses of nPEP. Due to the nature of this time-sensitive treatment option, it is recommended that the practitioner consult the most recent, up-to-date guidelines published by the CDC.

      Implementation Into Practice

      After discussing the risks, benefits, and alternatives of PrEP with TDF/FTC, the provider will start the initial diagnostic workup. An initial negative HIV test must be obtained within 1 week before the initiation of PrEP. Of note, the rapid oral swab is not recommended to screen for HIV when starting PrEP due to a decreased sensitivity compared with blood. An evaluation of renal function and hepatitis B serologies are indicated at the time of initiation. TDF/FTC is not recommended for individuals with an estimated creatinine clearance of <60 mL/min.
      Centers for Disease Control and Prevention
      Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 Update: a clinical practice guideline. March 2018.
      If hepatitis B surface antibodies (HBsAB) demonstrate insufficient immunity, the individual should be offered the hepatitis B vaccination series. If the hepatitis B surface antigen (HBsAG) is positive, the person should be evaluated for acute or chronic hepatitis B (HBV) because it indicates an active infection. PrEP with TDF/FTC is not contraindicated in a person with HBV; however, it is recommended that the individual be linked with an experienced HBV treatment provider, as both TDF and FTC can be used to manage hepatitis B. Monoinfected people taking TDF and/or FTC who then stop must have their liver function observed for recurrence of HBV replications, which can lead to hepatic damage.
      • Kourtis A.
      • Read J.
      • Jamieson D.
      ACOG Committee Opinion No
      595: Committee on Gynecologic Practice: preexposure prophylaxis for the prevention of human immunodeficiency virus.
      This initial diagnostic workup creates an opportunity to screen for STIs, including chlamydia, gonorrhea, and syphilis, and it may be completed during the initial workup. All reported sites’ exposure to chlamydia and gonorrhea—vaginal, oral, and/or anal—are screened. Table 2 lists the University of Washington’s STD Prevention Training Center’s Visual Guides for pharyngeal, rectal, and vaginal self-testing visual aids, which are resources to assist individuals in obtaining an appropriate specimen. A qualitative or quantitative human chorionic gonadotropin (HCG) treatment should also be completed if there is a concern about pregnancy. Table 3 outlines a list of required laboratory tests for initiation and continuation of PrEP, specifically TDF/FTC.
      • Yap P.K.
      • Loo Xin G.L.
      • Tan Y.Y.
      • et al.
      Antiretroviral agents in pre-exposure prophylaxis: emerging and advanced trends in HIV prevention.
      Following initiation of PrEP treatment, a follow-up appointment is scheduled within 30 days to review adherence and potential side effects.
      Centers for Disease Control and Prevention
      Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 Update: a clinical practice guideline. March 2018.
      Table 3Laboratory Testing Required for Initiation and Continuation of Oral TDF/FTC for PrEP
      Initial Laboratory TestingContinuation Laboratory Testing
      • HIV antigen/antibody conducted in a laboratory setting within 1 week of starting PrEP
      • Renal function panel, including and eCrCl
      • Hepatitis B serologies, specifically HBsAg and anti-HBs
      • HIV testing every 3 months before continuation of TDF/FTC
      • Renal function panel, including BUN/eCrCl at least every 6 months
      • Evaluate the need to continue PrEP for HIV prevention at least annually
      Suggested Laboratory TestingSuggested Laboratory Testing
      • NAAT for chlamydia and gonorrhea (oral, vaginal, and/or anal)
      • Rapid plasma reagin and TPA screening
      • Qualitative or quantitative HCG
      • NAAT for chlamydia and gonorrhea (oral, vaginal, and/or anal) at least every 6 months, even if asymptomatic
      • RPR and TPA screening at least every 6 months even if asymptomatic
      • Qualitative or quantitative HCG as indicated
      BUN = blood urea nitrogen; eCrCl = estimated creatinine clearance; HCG = human chorionic gonadotropin; HIV = human immunodeficiency virus; NAAT = Nucleic Acid Amplification Testing; PrEP = pre-exposure prophylaxis; RPR = Rapid plasma reagin; TDF/FTC = tenofovir disoproxil fumarate/emtricitabine; TPA = Treponema pallidum antibodies.
      Source: Centers for Disease Control and Prevention.
      Centers for Disease Control and Prevention
      Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 Update: a clinical practice guideline. March 2018.
      An HIV screening is performed on any person who engaged in activity with an increased risk of HIV infection since the initiation of PrEP. Following a negative HIV result, TDF/FTC is refilled with a 3-month supply. Providers should reinforce harm-reduction techniques, such as safe sexual practices with a contraception barrier, and behavioral changes, such as needle exchange programs in cases of illicit injection substance abuse.
      • Hershow R.B.
      • Gonzalez M.
      • Costenbader E.
      • Zule W.
      • Golin C.
      • Brinkley-Rubinstein L.
      Medical providers and harm reduction views on pre-exposure prophylaxis for HIV prevention among people who inject drugs.
      At the 3-month visit, the patient is rescreened for HIV, appropriate STI testing is offered, and renal status is reevaluated. During this visit, the provider assesses side effects, adherence, and behaviors that place the patient at a higher risk. If the patient and the provider determine that PrEP is no longer indicated, the provider reinforces the practices to reduce HIV risk. Documentation of the reason for discontinuation and the current HIV status are recorded in the patient record. TDF/FTC will decrease over the next 7 to 10 days after discontinuation; nonetheless, it is not recommended to engage in high-risk activities without the use of harm-reduction practices.
      Centers for Disease Control and Prevention
      Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 Update: a clinical practice guideline. March 2018.

      Conclusion

      Prescriptions for PrEP among AFAB have lagged despite there being many who meet the criteria for primary HIV prevention. Providers can prioritize primary HIV prevention for their female patients. Utilizing PrEP for primary HIV prevention gives AFAB the autonomy to make these decisions without their partners’ objection or consent. Providers can address barriers to PrEP utilization, such as lack of awareness, attitudes about PrEP, and access. PrEP therapy is a valuable tool for persons AFAB at the highest risk of HIV transmission. Providers can assist with decreasing new HIV infection rates among a vulnerable population unaware of the benefits of utilizing PrEP. HIV primary prevention is an integral part of any female’s routine health care. By being proactive in one’s overall health, one is a true partner in their care and can live their best life safely.

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      Biography

      Ingrid V. Martinez, DNP, FNP-C, is a nurse practitioner at SUNY Upstate University Hospital, Inclusive Health Services, Syracuse, NY, and can be contacted at [email protected]
      Justin M. Waryold, DNP, ANP-C, ACNP-BC, FAANP, is an assistant professor at SUNY Upstate Medical University, College of Nursing, Syracuse, NY.