● Antigen/antibody combination tests: detects HIV p24 antigen as well as HIV immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies. ● Antibody tests: detects HIV IgM and/or IgG antibodies. The “eclipse period” is the time period after infection, but before any diagnostic test is capable of detecting HIV following an exposure. 21 The “window Pre-exposure prophylaxis (PrEP) Antiretroviral PrEP is a way of preventing HIV transmission and should be prescribed for people at- risk for acquisition of infection. 22 PrEP to prevent HIV transmission was first approved by the FDA in 2012. Although PrEP has been shown to reduce the risk of new infections, uptake of PrEP is lagging, particularly among populations with a disproportionate burden. 22 According to the PrEPWatch website, only between 200,000 and 205,000 Americans currently use PrEP. 23 The FDA has approved 2 combination anti-HIV drugs in a single pill for use as PrEP: 24 ● Emtricitabine (F) 200 mg in combination with tenofovir disoproxil fumarate (TDF) 300 mg (F-TDF) is recommended for all adults and adolescents at risk for HIV through sex or injection drug use. ● Emtricitabine (F) 200 mg in combination with tenofovir alafenamide (TAF) 25 mg (F-TAF) is recommended for adults and adolescents at risk for HIV through sex, excluding people at risk through vaginal sex (cis-women/ transgender men). F-TAF has not yet been studied for HIV prevention for receptive vaginal sex.
period” is the time between potential exposure and an accurate test result. Improvements in testing continue to reduce the detection window period, and, therefore, the time to diagnosis and treatment of early HIV infection. Each type of HIV test has its own testing window, with the NAT capable of detecting HIV the earliest, followed by the antigen/ antibody combination test, and lastly, the antibody test. 21 PrEP medications are very effective at preventing HIV transmission. A retrospective analysis of the National HIV Surveillance System and national pharmacy data showed an independent and significant association between F/TDF PrEP use and a decline in the number of new HIV infections diagnosed in the US from 2012 to 2016 in communities where it was most widely used. 25 Unfortunately both provider and patient barriers limit the use of PrEP. These barriers include a lack of awareness of PrEP among at-risk individuals and providers, fear of stigma and/or side effects, provider implicit bias, distrust of the healthcare system, and a lack of access to medical care or financial assistance. 22 Even when PrEP is initiated, adherence is problematic. A study of 7148 individuals who initiated PrEP in 2015 at a national chain pharmacy reported only 56% persistence in year 1, 63% in year 2, and 41% from initiation to year 2, with the lowest persistence in women and individuals 18 to 24 years old.26 It is important to state also, that PrEP, unlike ART, which is currently recommended to be taken continuously for life, is designed to be taken during “seasons of risk” when acquisition of HIV is present. It may be stopped and started as frequently as needed depending on a person’s level of risk.
Case study 1 Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Robert is a 24-year-old Latino male. He is new to your practice. Robert presents with general malaise and a slight fever. He is a cook at a restaurant and has not felt well enough to go to work for a couple of days. During the patient history taking, Robert discloses that he is gay and in a 6-month relationship with another male. At first, he is evasive when you ask about HIV status, but eventually admits that his partner is HIV-positive. He further states that they continue to practice insertive anal sex without using a condom. Robert understands the inherent risks but fears his partner will leave him if he insists on using a condom.When you ask if Robert would like to be tested today, he becomes defensive and says no. Questions 1. What is the best way to proceed in this case? _______________________________________________________________________________________________ 2. How would you convince Robert to get tested and start on PrEP immediately if his test is negative? _______________________________________________________________________________________________ 3. What information could you provide to Robert to increase the likelihood that he will use condoms in the future? _______________________________________________________________________________________________
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Book Code: CT24CME
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