The Importance of Conducting PrEP Counseling With a Sex Positive Approach

At the American Society of Health-System Pharmacists' virtual 2020 ASHP Midyear Clinical Meeting and Exhibition, Elyse Tung, PharmD, BCACP, discussed key counseling points for pharmacists to address with patients when prescribing and managing pre-exposure prophylaxis (PrEP) use. Specifically, Tung noted the critical importance of a sex positive approach to the discussion in order to support a strong and comfortable relationship with the patient.

Tung explained that first and foremost, the provider should address the importance of regular adherence to PrEP during counseling, as adherence is strongly correlated with the efficacy of the medication. Tung noted that a patient missing a dose is fine as long as they take it as soon as they remember and make sure to note double up at the next dose.

It is also important to address the common adverse effects (AEs) of PrEP with patients, as symptoms such as upset stomach, nausea, headache, loss of appetite, and small changes in serum creatinine can occur.

“The first few side effects I often call the ‘start up syndrome,’ ” Tung said. “It usually occurs within the first couple of weeks of initiating PrEP. After that, they usually disappear and those patients tolerate the medication very, very well.”

Additionally, there can be less common AEs that are worth discussing with patients, including the potential for bone marrow changes, risk of hepatitis B viremia, and lactic acidosis. However, these AEs do not occur frequently, although they remain a concern worth addressing.

Tung explained there are also some important points to counsel patients on in regard to starting and stopping PrEP due to “seasons of risk,” which occur when patients stop and start PrEP of their own accord without consulting their provider.

“Some may be on [PrEP] long term for years and years [when this occurs], but many people will be on it for a year, and then they’ll stop and then they’ll restart, or even after several months, they’ll stop and restart. So, what’s really important to mention is that it takes 7 days [on PrEP] to get protection from [exposure during] anal sex, and for vaginal receptive sex, it takes 21 days to get up to protection,” Tung explained.

During the period before protection takes place, it is important for patients to continue to use condoms, despite being on PrEP. Counseling patients on the importance of using protection during this period before protection occurs can be critical in supporting the efficacy of the medication.

For this reason, it is important to counsel patients to not stop taking PrEP without consulting their provider. However, if the patient does stop taking it for any reason, they should not only begin to use condoms again, but they should not restart PrEP before first taking a human immunodeficiency virus (HIV) test in order to prevent any treatment-resistant cases of HIV.

However, there can be medically advisable reasons to consider the option of stopping PrEP. Such potential reasons for patients can include renal dysfunction, HIV seroconversion, allergic reaction or severe intolerance, or the patient is no longer at risk of HIV acquisition.

“Patients may discontinue PrEP on their own if they feel like their risk for HIV is reduced,” Tung said. “So, they either entered a monogamous relationship or they’re no longer dating, and protection will then wane [for them] 7 to 10 days after they stop daily PrEP.”

Patients should also be informed that PrEP does not protect against other sexually transmitted infections (STIs), so counseling on how to reduce risk of acquiring STIs, such as syphilis, chlamydia, and gonorrhea, while taking PrEP is necessary. Additionally, informing patients that regular follow up appointments will be required every 3 months is helpful in allowing them to plan for necessary follow ups.

Tung also noted that it is important to conduct a comprehensive sexual history with patients that is referred to as the “5 Ps.” This history asks questions that address the patients’ partners, practice (type of sex), protection used, past history of STIs, and pregnancy potential.

Tung explained that she was not taught how to conduct this history in pharmacy school, and that even today, pharmacy curricula may be lacking this essential component of PrEP counseling. Yet, Tung noted that the whole process is not a time-consuming element of the counseling session.

However, Tung explained that conducting the sexual history does require interview skills and the use of open-ended questions. The CDC developed resources such as the “Brief Sexual History Tool” and “A Guide to Taking a Sexual History,” both available on the agency’s website, for the purpose of making the interview process more seamless for providers.

Also, if the patient is transgender, questions should also be asked to address history of gender affirming hormones and gender affirming surgeries. For female to male transgender individuals, it is important to be sure to conduct pregnancy screenings at every follow up appointment while the patient is taking PrEP.

For all transgender individuals, PrEP does not affect their use of gender affirming hormones. It is advisable for transgender individuals, and transgender women specifically, to take PrEP, as transgender women are 49 times more likely to be living with HIV than other populations.

During these conversations, Tung noted the critical nature of counseling patients within a “sex positive” atmosphere in order to strengthen the patient-provider relationship and comfort level.

“When we have sex positive conversations and we openly talk about sex, we reduce the stigma around sex, and it also makes our patients more comfortable, more honest, and more forthcoming with information,” Tung said.

This sex positive environment also supports a more open conversation around HIV risk, sexual health concerns, and sexual activities and quantity that the patient may be engaging in.

“This is going to strengthen the patient-provider relationship,” Tung said. “I find when I have these types of conversations with patients, speaking at their level and with their language is the most appropriate way to develop this relationship.”

REFERENCE

Tung E, Mercier R. PrEParing Pharmacists to Prevent HIV. Presented at: 2020 ASHP Midyear Clinical Meeting and Exhibition; December 6, 2020; virtual.