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HIV preexposure prophylaxis in Canadian primary care and community settings

Amila Heendeniya, Ethan Tumarkin and Isaac I. Bogoch
Canadian Family Physician April 2019, 65 (4) 271-272;
Amila Heendeniya
Infectious disease resident, University of Toronto in Ontario.
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Ethan Tumarkin
Completing residency in internal medicine, University of Toronto in Ontario.
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Isaac I. Bogoch
Associate Professor in the Department of Medicine at the University of Toronto, a staff physician in the Division of Internal Medicine and Infectious Diseases with the University Health Network in Toronto, and the lead physician at the HIV Prevention Clinic at Toronto General Hospital.
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In Canada HIV continues to be a challenge, with more than 2500 new cases reported per year1 despite the considerable resources available compared with other countries that bear the brunt of this pandemic. Approximately 21% of HIV-infected individuals are unaware of their HIV-positive status and might be contributing to further disease transmission.1 Human immunodeficiency virus preexposure prophylaxis (PrEP) is an HIV prevention approach that protects individuals from infection, and the use of PrEP in Canada and worldwide has increased over the past few years. Canadians at elevated risk of HIV acquisition are approaching their family physicians for PrEP care in greater numbers. This article will outline several aspects of PrEP care to help you accommodate those patients in need.

PrEP care

Description of PrEP.

Preexposure prophylaxis is a proactive HIV prevention technique in which HIV-negative individuals who are at greater risk of HIV acquisition use antiretroviral medications to prevent infection.2 This approach has demonstrated success in considerably reducing the risk of HIV acquisition in clinical trials and in real-world situations,3 including Canadian settings.4

Indications for PrEP.

Indications for PrEP include men who have sex with men and trans individuals having condomless anal sex with individuals of unknown HIV serostatus, or with HIV-positive individuals who have a “detectable” viral load (meaning the viral load is greater than 40 copies/mL). Heterosexual individuals might also benefit from PrEP should they engage in vaginal sex with an HIV-positive partner with detectable viral loads. Last, people who inject drugs and share needles or other drug paraphernalia might benefit from PrEP.5

Facilitating PrEP care in clinical settings.

Providing PrEP care is rather straightforward. Before initiation of care, baseline investigations must first rule out HIV and other sexually transmitted infections (STIs) such as syphilis, chlamydia, and gonorrhea. In addition, individuals must be screened for hepatitis B and C infections, and should be vaccinated for hepatitis A and B if not immune. Baseline investigations should also include a complete blood count, creatinine test, urinalysis, and pregnancy test (if indicated). Also important, individuals being considered for PrEP should be screened for concomitant mental health issues and alcohol and drug abuse, and should be connected with appropriate care or harm reduction strategies where necessary.

Individuals who are starting PrEP require proper counseling on what this approach entails: PrEP involves taking 1 tablet that is a combination of emtricitabine (also called FTC) and tenofovir disoproxil fumarate (TDF) either daily or around the time of sex5 (“on demand” PrEP). Inform patients that, if used properly, PrEP can considerably reduce the risk of HIV acquisition by approximately 90% (or possibly more), but that it is not 100% protective.3–5 Patients typically receive a 3-month supply of the FTC-TDF combination drug and should receive follow-up in clinic every 3 months. Inform patients that PrEP will not protect them from other STIs such as syphilis, chlamydia, and gonorrhea, and that condoms should be used with sexual activity. Where appropriate, discuss and promote the use of sterile needles and injection drug harm reduction strategies. Finally, notify individuals initiating PrEP about the low potential for renal and bone toxicity while taking FTC-TDF.

A small tip on providing PrEP care based on our experience: We provide PrEP care to hundreds of individuals. For our patients taking PrEP, we prescribe a 4-month supply (rather than the recommended 3 months) of FTCTDF, and we follow up with patients every 3 to 3 and a half months. We believe this provides a bit of wiggle room for unexpected life events to occur (eg, illness, work, forgetfulness) and ensures that patients will still have medications and are protected.

Follow-up.

Quarterly follow-up appointments revolve around evaluating patients for drug adherence and toxicity, as well as signs and symptoms of HIV acquisition and other STIs; counseling around safe sexual and drug use practices; and determining whether an individual still requires PrEP based on his or her risk factors over the previous 3 months. Investigations at follow-up appointments include rescreening for HIV and STIs, along with completing a complete blood count and creatinine test.5 Preexposure prophylaxis can be discontinued 2 to 28 days after a patient’s last potential HIV exposure, only if he or she is no longer at increased risk of HIV acquisition. These patients should still have follow-up HIV testing 8 to 12 weeks later.

Removal of barriers to PrEP care

The wide-scale implementation of PrEP in Canada has been slow. Currently a small proportion of family medicine and infectious diseases physicians have included PrEP in their routine clinical practice; however, many more providers will be needed to accommodate the growing demands of Canadians. Fortunately, several events are enabling better PrEP access in community settings. First, FTC-TDF is now much more affordable, as generic versions are priced at approximately $200 for a month’s supply. Second, Ontario’s provincial drug program now subsidizes PrEP medications for those in financial need; the drug cost is covered in other provinces (eg, Quebec), and it is likely that other provinces will follow suit soon. Finally, Canadian PrEP guidelines are now published5 and freely available, and will provide front-line health care providers with the necessary tools to offer PrEP care. Prevention strategies for HIV are more accessible than ever. Let’s bring high-quality HIV prevention care to Canadians.

Notes

We encourage readers to share some of their practice experience: the neat little tricks that solve difficult clinical situations. Praxis articles can be submitted online at http://mc.manuscriptcentral.com/cfp or through the CFP website (www.cfp.ca) under “Authors and Reviewers.”

Footnotes

  • Competing interests

    None declared

  • This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to www.cfp.ca and click on the Mainpro+ link.

  • La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro d’avril 2019 à la page e145.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Public Health Agency of Canada
    . Summary: estimates of HIV incidence, prevalence and proportion undiagnosed in Canada, 2014. Ottawa, ON: Public Health Agency of Canada; 2015. Available from: www.canada.ca/en/public-health/services/publications/diseases-conditions/summary-estimates-hiv-incidence-prevalence-proportion-undiagnosed-canada-2014.html. Accessed 2019 Feb 20.
  2. 2.↵
    1. Bogoch II,
    2. Scully EP,
    3. Zachary KC
    . Antiretroviral medication for preventing HIV infection in nonoccupational settings. CMAJ 2012;184(10):1153-7.
    OpenUrlFREE Full Text
  3. 3.↵
    1. Volk JE,
    2. Marcus JL,
    3. Phengrasamy T,
    4. Blechinger D,
    5. Nguyen DP,
    6. Follansbee S,
    7. et al
    . No new HIV infections with increasing use of HIV preexposure prophylaxis in a clinical practice setting. Clin Infect Dis 2015;61(10):1601-3. Epub 2015 Sep 1.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Rajchgot J,
    2. Siemieniuk RA,
    3. Sivachandran N,
    4. Murphy P,
    5. Sharp A,
    6. Cicci A,
    7. et al
    . Feasibility of HIV pre-exposure prophylaxis as part of routine care in Toronto, Canada. J Acquir Immune Defic Syndr 2016;72(3):e80-1.
    OpenUrl
  5. 5.↵
    1. Tan DHS,
    2. Hull MW,
    3. Yoong D,
    4. Tremblay C,
    5. O’Byrne P,
    6. Thomas R,
    7. et al
    . Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. CMAJ 2017;189(47):e1448-58.
    OpenUrl
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Canadian Family Physician: 65 (4)
Canadian Family Physician
Vol. 65, Issue 4
1 Apr 2019
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HIV preexposure prophylaxis in Canadian primary care and community settings
Amila Heendeniya, Ethan Tumarkin, Isaac I. Bogoch
Canadian Family Physician Apr 2019, 65 (4) 271-272;

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Amila Heendeniya, Ethan Tumarkin, Isaac I. Bogoch
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