Hi, thank you so much for interest in pre-exposure prophylaxis. This video involves the initial PrEP visit, what providers and patients should know. My name is Joyce Jones. I am a physician at Johns Hopkins, and a PrEP provider in the HIV clinic at Johns Hopkins. >> And, hi, I am Glenn Fulton. I'm a PrEP patient navigator at the adult clinic here at Johns Hopkins Hospital. So the outline that we have for today's session, first we will introduce ourselves and talk about what PrEP is. Then Joyce, the provider, will take a history and assess HIV risk. Then she will conduct a physical exam and obtain labs. And then finally, she will schedule a follow-up. >> So what we thought is we would do a mock interaction between a provider and a patient for that initial visit. So you can see what it's like from the provider perspective, as well as the patient perspective. And we hope that we will have covered all of the things that you need to know and can expect in that initial PrEP visit. Hi. >> Hi. >> I'm Dr. Joyce Jones, nice- >> Nice to meet you. >> Nice to meet you, too. Welcome to the clinic. >> [SOUND] Thank you. >> How're you doing? >> Pretty well. >> Good, good, so I am a physician here at Hopkins and prescribe PrEP, pre-exposure prophylaxis. Can you tell me what brought you here to the clinic today? >> Sure, well, my name is Glenn, and my boyfriend is positive. >> Okay. >> So, that's mostly the reason why I'm here today. >> Okay, and how did you first hear about PrEP? >> So I have a friend that's in the outreach field, and he mentioned it to me, so I wanted to find out more about it. >> Okay, and what do yo know about PrEP? >> Really only that it's supposed to keep you from getting HIV. >> That's right, do you know what PrEP stands for? >> No. >> It stands for pre-exposure prophylaxis. So pre, meaning before, exposure meaning before being exposed to HIV infection, and prophylaxis meaning prevention. >> Okay. >> So just like you said, it's a medication that people who are at high risk for getting HIV infection, people can take a medication once a day to decrease their risk of getting HIV by over 90%. >> Wow. >> Do you know what the medication is that people use for PrEP? >> No, I just know that it's a pill. >> Yep, it's a pill, it's called TRUVADA. Right now, that's the only FDA approved medication for PrEP. There are other medications that are being investigated. But this is the only one, so far, that's been proven to prevent HIV infection. It contains two medications in one pill, tenofovir and emtricitabine. Have you heard about this before, this medication? >> No. >> Okay, so typically it's used, or in the past, it's been used only for people who have HIV infection. But as I said, these studies have been done that show, for people at high risk for HIV who do not have HIV, it decreases the risk of HIV infection by over 90%. >> Okay. >> Okay? Before we move on, I'm going to be getting a history from you, talking about your sex practices, really assessing your risk for getting HIV infection. >> Okay. >> And the we'll talk more about the medication and determine whether or not it makes sense for you to start on PrEP. >> Okay. >> Okay? And questions before we move on? >> Yes, does this pill have side effects? >> So, yes, when people first start PrEP, they can have headaches. They can get upset stomach, nausea, rash. Usually, those side effects go away after about a month. So we encourage people to keep taking the medication. We can give other medications to help with those symptoms, if needed. And they usual go away, like I said, after about a month. There's also the potential for kidney damage, and that's something that we monitor with lab tests. We'll also be doing a kidney function test before you start the medication to make sure that it's safe to start. It also can decrease the bone mineral density, which is the strength of the bones. That's not something that we typically monitor but it's something for you to be aware of. It hasn't been shown to be clinically significant. Meaning, we haven't seen increased rates of fractures in people who've been on PrEP. If you were at high risk for having low bone strength, then that's something that we would test for you. >> Okay. >> The other thing to know is PrEP was first FDA approved in 2014 [2012], so the long-term effects of PrEP are really not known. We know a lot about TRUVADA from our people, from patients who are HIV-infected. So we'll be monitoring for those kinds of side effects that we already know about if you were to start PrEP. >> Okay. >> Does that make sense? >> That makes sense. >> Okay, anything else before we move on? >> How do I pay for this? >> So do you have insurance? >> Yes. >> Yeah, so insurance typically does cover the medication. >> Okay. >> We live in Maryland, where PrEP has been covered by private insurers as well as by Medicaid. Other states, it varies, in terms of coverage for a PrEP, both the medications and the visits. If you do have any problems with co pays, we have a case manager who can help you with paying for the medication. There's also a pharmacy assistance program that our case manager can help you with as well. Through the company that makes the TRUVADA, to help you pay any co-pays that you're not able to cover. >> Okay. >> That make sense? >> That makes sense. >> We want to really minimize, if you are eligible for PrEP and you could benefit from PrEP, we really want to help you with that. So if you have any problems getting the medication because of payment difficulties, transportation difficulties, other things getting in the way of you taking the medication regularly, we would like to know about that and be able to help you with that. >> Okay. >> All right? >> All right. >> So now what I'm going to do is talk about, find out a little more about your medical history. >> Okay. >> Do you have any medical problems? >> No. >> And how about, have you ever been hospitalized? >> No. >> Are you taking any medications? >> I take allergy medication during the spring, ten milligrams of Zyrtec. >> Okay, do you have any allergies to medications? >> Not that I know of. >> Okay, and do you have a primary care provider? >> I do. >> And when's the last time you saw your primary care provider? >> A little less than a year ago. >> Okay, everything was good at your visit? >> Yes. >> And did you talk to your provider about PREP? >> No. >> And have you talked to your provider about your sex practices or your risk for HIV? >> Not really. >> Okay, so I'm a specialist in PrEP. So here at our clinic, we only provide PrEP services. >> Okay. >> We don't provide primary care for people who are HIV negative. But I'm really happy to work with your primary care provider If that would work better for you, if you do start on PrEP. >> Okay. >> So with PrEP, people come in every three months to get HIV testing and to make sure everything's going well with the medication. And really, we think that this does belong in primary care. So one of the things that I can do is, like I said, work with your primary care provider. If they don't know about PrEP, help provide some education and support for that, if that would be your preference. >> All right. >> Okay and have you had any surgeries at all? >> No. >> Okay, and how about vaccines? Have you been, are you up to date on your vaccinations, as far as you know? >> What vaccinations? >> So for example, hepatitis A and B, have you received those vaccines? >> I'm not sure. >> Okay, and how about human papillomavirus? >> What's that? >> That is a virus that is sexually transmitted that can cause genital warts, anal warts, and also anal cancer, penile cancer, vaginal cancer. And so there's a vaccine that was developed relatively recently that children are now getting. And also for young men and women who are of a certain age and who are sexually active, it's also recommended as well. >> Okay. >> So this vaccine helps protect against the strains that most commonly cause warts and cause cancer. >> Okay. >> Okay? So if you haven't had that, that's something that we should definitely give you today. >> Okay. >> Okay? How about any history of sexually transmitted infections? Have you ever had gonorrhea, chlamydia, syphilis? >> I had an STD once. >> Do you know which one it was? >> I believe it was gonorrhea. >> Okay, and you got treated for that? >> Yes. >> Okay, and when was the last time you got tested for HIV? >> It was about three months ago. >> Okay, and that test was negative? >> Yes. >> And you mentioned that your boyfriend is HIV positive? >> Correct. >> How long have you been together? >> About nine months. >> Okay, and when was he diagnosed with HIV? >> He was diagnosed about eight months ago, so a little after we got in a relationship. >> Okay, how's he doing? >> He's doing well. He started his treatment shortly after he was diagnosed. >> Okay. >> I'm not sure how well he's taking it. >> Okay, how is he handling his diagnosis, is he- >> Seems well to me, but we don't really talk about it. >> Okay, how are you doing? >> I'm all right, it's just that our sex life is complicated because of this, so- >> Okay, okay, and do you use condoms when you have sex? >> With my partner, yes. >> With him, with your boyfriend you use condoms all of the time. >> All of the time. >> Okay, and you mentioned that he is on treatment. He's on antiretroviral therapy? >> Yes. >> Okay, do you know what medications he's on? >> I'm not sure. >> And do you know, have you heard the term viral load before? HIV viral load? >> I have but I'm not really familiar. >> Okay, so when people get infected with HIV, what happens is the virus makes copies of itself in the immune system of the body. And, as physicians, what we do is we measure the number of copies in the blood of that HIV virus. The number of copies that we measure in the blood is called the viral load. >> Okay. >> The goal for anybody who is infected with HIV is that they achieve what we call an undetectable viral load. >> What does that mean? >> That means that when we look for copies of virus in the blood, we don't find any copies of virus. It doesn't mean that the virus is gone from the person's body. >> Okay. >> It just means that they're on those antiretroviral medications that make it so the virus cannot make copies of it's Itself. When the virus can't make copies of itself, it's not out and circulating in the blood. >> Okay. >> Okay, so, our goal for everybody who has HIV is that they achieve this undetectable viral load. They achieve that by getting on the right medications and taking them every single day. >> Does that mean it is harder to pass on if it's undetectable? >> Yes, so people who have undetectable viral load, there have been a couple of large studies looking at couples where one sex partner was HIV positive, and one of the partners was negative. If the partner who is HIV positive got on antiretroviral medications and achieved and maintained an undetectable viral load, there were no transmissions of virus in those studies. >> Wow. >> Some of the HIV negative people did get infected with HIV, but when they looked at the virus itself, it was an infection from a different partner. >> Okay. >> Okay, so in your situation, the fact that he is on meds is good. But the fact that he doesn't take medications consistently is not good for him. Because people who are undetectable and stay undetectable live longer and are much less likely to get sick from HIV. And then can also protect their sexual partners from getting infected as well. >> Okay. >> Okay? So if you would want to bring him in to visit together, I'd be happy to do that. As much as you feel comfortable in your relationship. To help him with his HIV treatment, that would be great. >> Yeah, I want to support him, so. >> Okay, okay, great. And then in terms of other partners, so you have been with your boyfriend for about nine months. And how about any other partners in the last year, how many other sexual partners have you had? >> Well, honestly, I've had two outside of my relationship. >> Okay, and are your partners men, women or both? >> They're men. >> In general, do you have sex with men, women or both? >> Both, I've had sex with women in the past. >> Okay, in terms of your gender identity, do you consider yourself male, female, neither? >> I consider myself a male. >> Okay, and how about sexual orientation? Do you consider yourself gay, bisexual, Straight, neither? >> I consider myself a bisexual. >> Okay. And in terms of your sexual practices, when you have sex, do you have anal sex? >> Yes. >> And do you have anal receptive sex, meaning being a bottom? >> Yes. >> And how about insertive sex, where you're a top? >> Yes. >> Okay, and how about giving oral sex do you also give oral sex? >> Yes I do. >> Okay, and you mentioned that you use condoms with your partner. Do you use condoms with all of these sex acts? With anal sex and with oral sex? >> Honestly, not 100% of the time. >> Okay. And how about with your partner outside of your boyfriend? Do you use condoms with those partners? >> So, I'll use condoms 100% of the time with my partner, but not with my outside partners. >> You do, okay. And including with oral sex too? >> Yes. >> Okay. But you don't with your outside partners? >> Right. >> Do you know the HIV status of your other partners? >> No, I don't. >> Okay, and why don't you use condoms with your other sex partners? >> I think for me it's just the feeling of condoms. I'm not really too keen on the feeling, so I don't really care to use condoms. >> Okay. Okay. So, just in general, in terms of HIV risk, the fact that you're not sure of the HIV status of your partners, you know they could have HIV and could have detectable viral load. And so you're putting yourself at risk for getting infection. >> Right. >> Regardless of if we use PrEP, if you start on PrEP. So, PrEP decreases people's risk of getting infection by HIV by over 90%. Okay? >> Okay. >> It does not protect against other sexually transmitted infections. So it won't protect against gonorrhea, chlamydia, syphilis, hepatitis B, hepatitis C, human papilloma virus, herpes. And so, for that reason, we recommend that even people who are on PrEP continue to use condoms. >> Okay. >> Okay. People sometimes think that with HIV, or with sexually transmitted infections, that they would feel it. That either they or a partner would have symptoms, or you could tell if they had an infection. But many people have these infections and there are no symptoms at all. >> Okay. >> Okay. So part of PrEP, what we want to do is not just write a prescription for medication that prevents HIV, we want to help you with your all over health and with your sexual health. So, while you're engaging in sex, which is enjoyable, we want to make sure that you're as safe as possible and that you have all the information to protect yourself. >> Okay. >> Okay. The other thing about the sexually transmitted infections is that they actually increase the risk of getting HIV. And if people, if they have HIV and they have a sexually transmitted infection, it increases their risk of passing HIV on to others. So, what we will do as part of the evaluation is screen you for all of these infections, including HIV. >> Okay. >> If you have the infection, obviously, we'll treat you. And we'll do that screening, definitely HIV, every three months. Probably sexually transmitted infections every three months as well, depending on your risk. >> Okay. >> Okay? Any questions about that? >> Yes. Is PrEP more effective than condoms while protecting me against HIV? >> Yep. It's estimated that condoms protect about 70% from HIV infection. Or as I mentioned, the Truvada protects by over 90%. >> Right. >> In some studies, when they gave many people PrEP and they followed them over time, if they took the medication very consistently none of the patients over a year got infected with HIV, even though they were at high risk for getting infected. >> Okay. >> Okay. One of the other things is and, again we'll talk about this more, is if you do start PrEP we'd want you take the medication every day. >> Okay. >> So, the studies have shown that people who didn't take the medication consistently were more at risk for getting infected with HIV. >> So adherence is very important. >> Yeah, so over 90% comes with taking the medication very, very consistently. It went down to 50% for people who weren't taking the medication almost every day. >> Okay. >> Okay? So, when was the last time that you were sexually active? >> I would say, almost two weeks ago. >> Okay. And over the last six weeks, have you had any fevers or chills? >> No. >> Have you been sick at all? No. >> Sore throat? >> No. >> Rash? >> No. >> Muscle aches or pain, joint aches or pain? >> No. >> Okay, these are the symptoms that people can have with acute HIV infection. So when people initially get infected with HIV, they can end up having flu-like symptoms. So, part of what we'll want you to do if you do start on PrEP is to really to monitor for any of those symptoms. And then we would want to get you tested for HIV right away. >> Okay. >> So that we can make sure that you weren't infected. We don't want people to take PrEP, to take the Truvada, alone if they have HIV infection. >> Okay. >> Okay? because that's not enough medication to suppress the virus. And if people take that medication, and they have HIV, and they're not taking anything else, then the virus can change so that those medications and other medications won't work to fight the HIV. >> Okay. >> Okay. So we really want to make sure that you're only taking the Truvada if you're really HIV negative. >> Understood. >> Okay, as part of that, we're going to be doing your HIV testing today. And I want you to avoid sexual intercourse from today until at least seven days after you start PrEP, if you you do start PrEP. >> Why seven days? So, it takes about seven days for the medication to reach affected drug levels, in the anal and rectal area. >> Okay. >> Okay, so for women, it takes about three weeks to reach those affected areas, and in the blood it about three weeks. >> Okay. >> So in order to make sure that you have the maximal protection, in that you're only taking the medication when you are not infected with HIV, that is a strong recommendation. >> Okay, so the pill does not work the first day I take it. >> No, no. So, that's a really important thing. Do you think that you'll be able to avoid sex for that period of time? >> For seven days. No problem. >> Okay. So, you're feeling well. And how about in terms of your family history? Anyone in your family have any problems with kidney disease? >> Not that I know of. >> How about bone disease? >> No. >> Okay, any other significant family history? >> No. >> Okay. Have you ever had any problems with mental health issues? >> No. >> Are you feeling depressed? >> No. >> Have you ever tried to hurt yourself? >> No. >> How about any alcohol use? >> A little. >> Do you drink every day? >> No. >> Do you drink every week? >> Mm. Maybe every other week. >> Okay. And what are the most number of drinks that you'll have at a time? >> Just about two shots. >> Okay. And how about any drug use at all? >> No. >> And how about ever inject any drugs in the past? >> No. >> All right. And how far did you go in school? >> Just a high school diploma. >> Okay, are you working? >> Yes. >> Okay, and are you living with anybody? >> Just my partner. >> What kind of work to you do? >> I just work at Barnes and Noble. >> Okay, how's that going? >> It's work. >> Okay, it's a job. >> Yeah, it's a job. And do you have any children? >> No, not yet. >> Okay. And in terms of your relationship with your boyfriend, and with your other partners, is that a safe relationship? >> Safe, meaning? >> Meaning that you don't feel threatened physically. >> No, no. >> Okay. What were you thinking of when I asked you about safe? >> I don't know, just I don't know. [LAUGH] >> Okay, all right. Yeah, do you have any fear of physical abuse at all? >> No. >> How about sexual abuse? >> No. >> How about in the past? Any history of physical or sexual abuse? >> No. >> Okay. How about with your family and friends and for yourself in terms of your sexual orientation, is that something that has been a problem for you or? >> It was in the past. But they're pretty open-minded about it now. >> Okay, okay. And how are you feeling about your sexual identity, and how things are going with your sex life? >> I'm pretty comfortable with myself at this point. >> Okay, okay, good, good. Well, like I said before, this isn't just about writing a prescription. This is to really promote your health, and your sexual health too. >> I appreciate that. >> Okay, great. All right, so we've reviewed a lot during this time. We' talked about what PrEP is. We talked about the medications, what some of the side effects are. I feel like I have a good history in terms of your risk of getting infected with HIV. The next step is, really, for me to do an exam, and then we'll get some lab work done. Do you have any other questions at this point? >> Not at this point. >> Okay, all right, so let's go, and we'll do the physical exam. >> Okay. >> Okay, so now we're back from the physical exam. You want to make sure you ask patients ahead of time if they feel comfortable doing the genital exam and the perianal exam. When you do the exam, you're also going to want to swab the areas of potential exposure to gonorrhea and chlamydia. So you would swab the throat. You would swab the anal and rectal area. For women, a vaginal swab for gonorrhea and chlamydia. For men, I usually get a urine sample. I might not do a urethral swab. You're going to check for enlarged lymph nodes, and check for any lesions in the genital area and in the perianal area. So that now that we've finished the exam, you're going to go and get some blood work done. >> Okay. >> So the testing that we're doing today, just as a review, is we're doing one as an HIV test >> You said that your last sex was about two weeks ago? >> Mm-hm. >> So we're going to do the most sensitive test, which becomes positive earliest in infection. So this will tell us that one to two weeks from before today, whether or not you were HIV negative. >> Okay. >> Okay. I did the swabs for gonorrhea and chlamydia. You're going to give urine also for that. >> Okay. >> Your urine, we're also going to test for protein. And we're going to test the blood for something called creatinine to make sure your kidney function is good, so that it's safe to start Truvada. We're also going to do a blood test for syphilis. We're going to check to see if you are protected against hepatitis A and B, and if you're not, then we'll give you a vaccine for that. We'll also check you for hepatitis C. So these hepatitis infections can cause liver problems. >> Right. >> So, like I said, I'll give you the vaccine for A and B. There is not one for C. >> If you are positive for infection, then we would refer you for treatment. >> Okay. >> Okay, you could still get PrEP, but it would be important to get treatment as well, all right? >> Okay. >> And today we're also going to give you the human papillomavirus vaccine as well. >> Okay. >> Okay? So, we'll schedule you for follow-up in about a week to go over all of your blood work, >> Okay. >> And all of your lab tests. Again, don't have sex from today, >> Seven days. >> Until, well, it's going to be more than seven days, because I'm going to see you in about a week, >> Okay. >> Before we got your tests results back. And then from then, once we've prescribed the PrEP, it would be seven days after that. >> Okay. >> Okay? If you are HIV-positive, we'll refer you right away for treatment. >> Okay. >> Okay? So I'm also going to give you some handouts here. So this is a handout that is just general information about PrEP. It's a lot of information that we discussed today. >> Okay. >> This is information about acute HIV infection that we talked about. So when people first get infected with HIV, what are the symptoms to look out for. >> Okay. >> Okay? And I'll want you to contact us right away. And I'll give you information about how to reach us, okay? >> Okay. >> This is, again, general information about PrEP as well. >> Okay. >> And then there's also information about the pharmacy assistance program on the back. So if you want to go ahead and call your insurance company, and find out about coverage for the medication, coverage for visits, labs, and things like that, that would be useful. >> Okay. >> You can also, if it looks like you're going to need help with the copays, this is the pharmacy assistance program. >> Okay. >> We also do have a case manager, and you met our navigator as well, who can help you with any of those kinds of issues. So if you're having a problem with your copays, if you're having problems with transportation, things like that. The other thing we didn't talk about is how well you take medications. Do you typically, when you need to take medications, do you remember or do you have a hard time remembering? >> Yeah, I don't have a hard time taking pills. >> Okay, so like I said, you want to take it consistently every day at about the same time every day. >> Okay. >> You would take it with or without food. And if you needed a pill box or something like that, and to help you remember, or sometimes people set alarms in their phone to remember. >> Right. >> You could even practice in the next week to see how you do like with an vitamin or something like that. >> Okay. >> Okay, but we'll see you back next week. If you have any questions in the meantime give us a call. >> Okay. >> Here is an brochure about our program. And here is the contact information for me, the nurse that I work with, and our case manager and our navigator. >> Okay, thank you. >> You're welcome. And so they'll schedule you for follow-up out front. >> Okay. >> Any other questions? >> Yes, where does my information go? >> That's a very important question. So all of the information here is protected health information. So only people who should have access to that information will be able to see the information. >> Okay. >> Or should enter your chart to look. Other hospital employees from other departments can go into the system but we can audit that. So if you're concerned that somebody went into your chart, we have the ability to look at that, and see that only the people that should've been in your chart are in your chart. >> Okay. >> If your test for HIV or for any of these STDs becomes positive, it does get reported to the Health Department. >> Okay. >> Okay, so. It is done confidential manner, and again, it's very protected. >> Okay. >> So only people who should know will have that information. >> Okay. >> If you do test positive for HIV, the health department will reach out to you to make sure that any potential partners also get tested. >> Okay, so if I'm negative, the health department won't be notified. >> No. >> Okay. >> Yeah, all right? >> Thank you so much. >> You're very welcome. It was really nice to meet you. >> Nice meeting you too. >> Okay, thanks. Okay, so that was really the initial visit. We had this scenario where, in that visit, I as the provider introduced PrEP, got the history, did the exam, and obtained labs at that time. In the clinic, we actually have patients first meet with a nurse. And the nurse does the intake and does the patient education and obtains labs at that time. The important things, no matter how you do it, it's important that the patient gets all of that information, that you as the provider get all of that information. And that the HIV test that you obtain, that you do not prescribe PrEP if that test was done more than seven days from the time you're prescribing PrEP. So you really want to make sure that the patient is truly HIV negative before you write that prescription for PrEP. When you're deciding what HIV test to order, you should ask the patient when was their last potential exposure to HIV. So when did they last have sex? If it's been within the last 72 hours, then you should consider prescribing non-occupational post exposure prophylaxis. I go into this in another part of this Coursera course. But basically, that's prescribing a full regimen of antiretroviral medications, after potential high-risk exposure to HIV, to prevent acquisition of HIV. So again, that's if somebody has had a high-risk exposure within the last 72 hours, then consider prescribing that nPEP. In terms of other patients, so with the nPEP, you should be doing HIV testing. You should get an HIV viral load to start. And then for all of your patients, you should know, what is the HIV test that's used at your institution? So we, for decades, have been using the standard HIV test, so the third-generation HIV antibody test. And that becomes positive within three to five weeks of infection. So you have a three to five week window period where someone could be infected with HIV, but the HIV test is coming back negative. Since then, there's a fourth-generation HIV antigen antibody test that will become positive anywhere from two to four weeks after infection. This is the test that we most typically use at our institution. Again, you should know what's available at your institution, and also know the characteristics of the test that you are using. And then the test that becomes positive soonest is the HIV RNA test. And that becomes positive within one to two weeks of infection. So knowing when the person last had sex will help guide which of these tests you're going to choose at your institution. Also, different institutions are going to have different availability of ordering these tests. And there financial considerations, as well, when you're creating your algorithms for HIV testing. So this gives you a summary of what we went through in our scenario where we had the visit with the patient. We discussed what PrEP is. If patients have any misconceptions about PrEP, that's something that you should be sure to review in that visit before you prescribe PrEP. With my particular patient, he was fairly sophisticated. So when I introduced a concept, it seemed pretty clear that he understood what I was saying. You may have other patients who come in already with lots and lots of information, and you're just confirming what it is that they already know. And then there are some patients who may have some difficulty really understanding the concept of PrEP and may have different levels of understanding of HIV transmission and risk. So you need to really make sure you tailor that counselling part to your patient. We also got the lab tests. I talked to you about the HIV test and some decision making about which test to order, depending on what's available and the patient's last episode of sex. Checking a metabolic panel and a urinalysis to check for any preexisting kidney disease. Checking viral hepatitis serologies, and if people are hepatitis A and/or B negative, giving them immunization. If they hepatitis B or C infection, making sure they get referred for treatment. Doing STI screening, gonorrhea and chlamydia, checking all of the orifices which may have been exposed, and doing serologic tests for syphilis. And then checking a pregnancy test for women. So after you have that negative HIV test, remembering that you want to counsel patients to not have intercourse or exposure to HIV, potential exposure to HIV. From the time that you do the test until, for men, it would be seven days after starting PrEP. And for women and injection drug users, about three weeks, to make sure those drug levels are at the appropriate levels for protection. Having someone call about two weeks after starting PrEP to make sure that they are adherent to the medication, aren't having any problems with taking the medication, and aren't having any side effects. At each visit, you want to make sure that you're reviewing adherence, the importance of adherence. And how well someone is going to be able to take the medication consistently and also come for follow up visits on a regular basis. It's standard that once patients have been established on PrEP, they'll come at least every three months. But if you have patients who have poor adherence or intermittent use, you may want to schedule visits more frequently. So after I meet my patient one week later to go over lab results and prescribe PrEP, I'm going to have them come back in about 30 days to assess for side effects. If your patient, before you prescribe PrEP, has borderline renal function or is at increased risk for renal disease, then you could consider repeating that serum creatinine. And at every visit, discussing risk reduction and providing condoms. I then write a prescription for 60 more days and then have them come back for HIV testing and follow-up assessments. And here's an outline for what will happen at each of those visits. So at the 3-month visit, 6-month, 9-month, 12-month visit, each visit doing an HIV test. For women, doing pregnancy test, discussing risk reduction, and providing condoms. Every three months, doing a serum creatinine and calculated creatinine clearance to make sure that their renal function is stable and that it's safe to continue the Truvada. And then doing STI screening, in this algorithm, it talks about asking about symptoms every three months, with screening every six months. If patients, in my practice, if they have any potential exposure, I actually do screening every three months. And then you want to also check for hepatitis C serologies for men who have sex with men, IV drug users, and patients with multiple sex partners, every 12 months. And you also do want to revisit the risk-benefit ratio for PrEP. So PrEP is not something that is a medical condition. It's a risk for getting HIV infected. If somebody's risk changes and they're no longer at high risk for HIV infection, then that should be discussed in terms of stopping PrEP. Glenn, did you have anything else you want to add from the patient perspective about this initial visit and the follow-up visits? >> Yes, as a patient, you may be hit with a ton of information that you're not familiar with. So even though I may understand it, you may not. So please do not be afraid to ask any questions. >> All right, thank you so much for your time, and best of luck with PrEP. >> Good luck.
