Providing Education and PrEP for Teens at Risk for HIV

In a recent PediaCast CME, Mike Patrick, MD, and Megan Brundrett, MD, share important information about offering PrEP and HIV-related education in your primary care practice.

About 20% of new cases of HIV, the virus that causes Acquired Immunodeficiency Syndrome (AIDS), are occurring in youth aged 13 to 24. HIV/AIDS is a life altering, life-long infection that, while treatments and survival rates have improved, can be deadly.

Improved treatment is also linked to improved prevention. Two drugs that are part of a successful three-drug treatment cocktail are also approved by the Food and Drug Administration (FDA) for prevention. Pre-exposure Prophylaxis (PrEP) for HIV is a once daily pill consisting of emtricitabine and tenofovir alafenamide (Descovy) or emtricitabine and tenofovir disoproxil fumarate (Truvada). Both formulations are available for any individual weighing more than 35 kg (about 77 lbs).

When used as prescribed, PrEP reduces the risk of getting HIV from sex about 99%, according to the Centers for Disease Control and Prevention (CDC). For injection drug users, available data indicates that PrEP reduces the risk of getting HIV by at least 74%.

In a recent episode of PediaCast CME, Megan Brundrett, MD, medical director of the Family AIDS Clinic and Educational Services (FACES) program at Nationwide Children’s, sat down with Dr. Mike Patrick to discuss what pediatricians need to know to begin offering PrEP to youth who are at risk for contracting HIV.

“While pediatricians can refer patients to clinics that specializes in care and prevention of HIV, such as the FACES clinic here at Nationwide Children’s, not every community has access to this type clinic,” says Dr. Brundrett. “Pediatricians can easily equip themselves to offer the care and education needed to help teens at risk for HIV exposure.”

Screening for Risk

The first step in starting PrEP is screening for risk. By asking social risk questions during the one on one part of the well check, pediatricians can engage patients and ask questions that will help them ascertain their risk of HIV exposure.

Dr. Brundrett offers some suggestions for these conversations:

• Ask specific questions. Don’t just ask if a teen is having sex, give them options about what types of sex they might be having. For example, “Are you having vagina, anal or oral sex?”
• Ask about needle-associated drug use and about needle sharing.
• Be aware that these conversations can be uncomfortable. Conversations about sexual activity and drug use early in the patient/physician relationship can normalize these topics and encourage patients to be more open and truthful in their responses.
• Explain why this information matters and about HIV risk.
• Be prepared to support the teen who may not want to share risk factors with parents in order to access PrEP.

Get Appropriate Labs

If you’re risk screening and subsequent conversations with the patient and caregivers lead to the decision to start PrEP, certain labs must be obtained before starting the medication.

• Screen for HIV.
• Screen for hepatitis B and C.
• Screen for kidney function.

For HIV, a blood test should be obtained. If the patient shows signs of acute HIV infection, an HIV viral load test should also be performed. A swab for HIV is not recommended.

Labs for HIV, kidney function and hepatitis viruses B and C (HVB and HVC) should be negative within one week prior to starting PrEP.

Additionally, Dr. Brundrett recommends performing sexually transmitted infection testing for sexually active teens, specifically for chlamydia and gonorrhea, by swabbing any location where sex is occurring. A urine test alone can miss STIs in some cases. A blood test for syphilis is also recommended.

Once starting PrEP, patients should be counseled that it takes time to reach maximum protection. PrEP reaches maximum protection from HIV for receptive anal sex at about 7 days of daily use. For receptive vaginal sex and injection drug use, it takes about 21 days of daily use. No data are currently available for insertive vaginal or anal sex.

Follow Up With Patients

Follow up is dependent on the patient’s needs. Providers can only prescribe 90 days of PrEP at a time, and negative tests are required prior to each refill.

For adolescent patients, Dr. Brundrett recommend more frequent follow-ups.  Adolescent adherence declines over time, she says. “For me, if they are 15 to 17, we meet monthly to check adherence and build relationship.”

Follow up to ensure adherence to the medication is essential because PrEP is much less effective when not taken as prescribed. For the patient to receive the full benefit of the medication, it must be taken consistently.

Dr. Brundrett also notes that PrEP is not necessarily a life-long medication. The need for PrEP ebbs and flows for many individuals depending on relationship status, drug use and other lifestyle factors. Building a relationship with patients so that they can come to you when they need PrEP or before they engage in higher risk behaviors can be a tremendous support for reducing new HIV infections.

This article appears in the 2021 Fall/Winter print issue. Download the full issue.