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Putting PrEP into Practice

A young man who repeatedly engages in high-risk sexual activity with other men requests pre-exposure prophylaxis to prevent HIV infection. Do you oblige?

A 29-year-old man goes to the emergency department (ED) to request post-exposure prophylaxis (PEP) to prevent HIV infection. He has just returned from a week-long vacation, during which he had unprotected oral and receptive anal intercourse with several men whose HIV status he does not know. His last HIV test was 6 months prior to this ED visit, and the result was negative. He reports no medical problems and is not taking any medications. He receives a 28-day course of tenofovir/FTC + lopinavir/ritonavir PEP.

Four days later, the patient has a follow-up visit with his primary care provider (PCP), who is aware that he has received at least three similar courses of PEP during the previous 4 years. His HIV antibody test has again returned negative. He says he is aware of when he is going to put himself at high risk for HIV infection (usually during vacations and particular weekends) and would like a supply of tenofovir/FTC to take during these periods; however, he does not want to take the drugs continuously.

If you were the PCP, what additional history would you obtain? Would you try to change the patient's high-risk behavior? If so, what specifically would you say to him? Would you recommend tenofovir/FTC pre-exposure prophylaxis (PrEP) for him? If so, would it be continuous or intermittent? How frequently would you monitor for HIV, other sexually transmitted infections, and tenofovir/FTC toxicity? If you would not prescribe PrEP, what is your reasoning?

TELL US WHAT YOU WOULD DO

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Published in Journal Watch HIV/AIDS Clinical Care February 28, 2011

Reader Remarks:

Review and add to remarks on this article

• First, do no harm
  Carey R Terry, UT Family Practice Memphis, 1 Mar 2011 4:13 PM EST
  Specialty: Family Medicine
  Though it is reasonable to expect that this type of prophylaxis will hasten the senescence of tenofovir, drugs are to... [more]
• Pre-Exposure Prophylaxis
  Marc A. Tanenbaum, 1 Mar 2011 4:13 PM EST
  Specialty: Pediatrics
  My concern about PreP is that it creates an illusion of safety and implies that with PreP in the absence... [more]
• Pre-exposure prophylaxis
  d h, 1 Mar 2011 4:13 PM EST
  Specialty: Family Medicine
  Prescribing pre-exposure prophylaxis for a high-risk behavior to an apathetic person is like purchasing ammunition for a repeat bank robber.... [more]
• PrEP decision and consequences
  Joalie E Davie, Santa Fe, NM, 1 Mar 2011 4:13 PM EST
  Specialty: Unspecified
  How does one set healthy boundaries and manage the care of a patient with an addiction? Since his behavior is... [more]
• Patient autonomy
  Tom Boyles, South Africa, 1 Mar 2011 4:15 PM EST
  Specialty: Infectious Disease
  Check HBV status and vaccinate if negative, check creat. Advise TDF/FTC to be taken 1 weeks before and 4 weeks... [more]
• Sorry no HIV prophilaxis, rather change risky behavior.
  James Voigt, MD, Allegiance Family Medicine North, 1 Mar 2011 4:15 PM EST
  Specialty: Family Medicine
  I would not recomend HIV prophilaxis for ongoing risky behavior, rather that risky behavior needs to change or else my... [more]
• reason for not prescribing PrEP
  P F, Ireland, 1 Mar 2011 4:15 PM EST
  Specialty: Infectious Disease
  To justify prescription to one individual sets a precedent whereby this should be prescribed to all who seek it. This... [more]
• PrEp
  Suhash Patel, 1 Mar 2011 4:16 PM EST
  Specialty: Internal Medicine
  PrEP gives patients the idea that risky behavior can be in part "safer" with these medications. I believe as healthcare... [more]
• Putting PrEP into Practice
  Dr Murugan Sankaranantham, Tirunelveli- India, 1 Mar 2011 4:16 PM EST
  Specialty: Dermatology
  Dear Sir, I would not prescribe TNF/FTC as PrEP as no PrEP is 100% foolproof. If one acquires HIV inspite... [more]
• PrEP
  monchai siribamrungwong, Lerdsin General hospital, 2 Mar 2011 11:06 AM EST
  Specialty: Internal Medicine
  PrEP for this situation, may be harmful. According to the PrEP is designed for HIV prevention after accident, not for... [more]
• Double Standard?
  Melissa Dattalo, 3 Mar 2011 5:50 PM EST
  Specialty: Internal Medicine
  How is this different than prescribing a PPI for heartburn when a patient refuses to give up coffee or a... [more]
• Why I would not prescribe
  John GILBERT, 7 Mar 2011 12:35 PM EST
  Specialty: Family Medicine
  Not being an expert in STI, I would refer to a specialist. However, I would like to know what evidence... [more]
• Putting PrEP into practice
  Musa Abubakar Garbati, KFMC, Saudi Arabia, 7 Mar 2011 12:35 PM EST
  Specialty: Infectious Disease
  A. Additional info. 1). Condom use. 2). Heterosexual partners. 3). Partner(s) also on PrEP?. 4) Chances of changing his behavior?... [more]
• PrEP
  Olumuyiwa Akingunola, Abeokuta, Nigeria, 7 Mar 2011 12:35 PM EST
  Specialty: Family Medicine
  I think the previous doses of PrEP doses is reinforcing his risky behaviour. he will go on to have HIV... [more]

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