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Providing PrEP in Practice
Doctors who had prescribed PrEP or who were willing to prescribe PrEP were asked under what circumstances they would provide it. Answers to this question fell into two categories, as follows:
- most would provide it if a patient was at risk for becoming infected
- most would provide it if a patient requested it
The main risk factor that would encourage doctors to provide PrEP was as follows:
- if a patient had an HIV-positive partner who was not taking potent combination therapy for HIV (commonly called ART or HAART)
Other situations that would prompt a prescription for PrEP included the following:
- if a patient reported engaging in unprotected intercourse
- if a patient disclosed that he/she had multiple sex partners
- if a patient was attempting to become pregnant with an HIV-positive partner
- if a patient was in an abusive or coercive sexual relationship
- if a patient was a heterosexual commercial sex worker
- if a patient was a transgender woman who had factors that placed her at risk for HIV
The EIN researchers stated that "a minority of respondents would provide PrEP to [people who injected street drugs]."
HIV screening most commonly involves testing blood or other bodily fluids for the presence of antibodies to HIV. However, in cases of early HIV infection, the immune system may take up to several weeks after exposure before producing antibodies. In such cases, screening blood for the genetic material of HIV (using assays called nucleic acid amplification tests, or NAAT) can sometimes uncover very early HIV infection.
The survey asked physicians about their potential use of nucleic acid testing (NAAT) and many disclosed that they would use NAAT to screen their patients for early HIV infection prior to prescribing PrEP and every three months while their patients were taking PrEP.
Taking medicines every day exactly as prescribed and directed is called adherence. This is essential if medicines are to achieve their full value, and in the case of PrEP, provide the greatest degree of protection.
There is no method for generally assessing adherence that is robust, fast, simple and cheap, so doctors often use different means of doing so. In the EIN survey, 81% of physicians responded that they would rely on their patients' self-reports for assessing adherence to PrEP. However, the EIN researchers caution that relying on patients to self-report adherence to PrEP may not be useful. This concern arises because in two studies of PrEP patient self-reports of adherence did not appear to be reliable. For instance, in one study called Voice, participants told researchers that they were 90% adherent yet only 30% had detectable levels of tenofovir in their blood. In another study called FEM-PrEP, 95% of participants reported taking PrEP exactly as directed but a much smaller proportion (between 25% and 33%) had detectable tenofovir in their blood.
Other responses from physicians about adherence monitoring included the following:
- 45% would rely on pharmacy records (consulting a pharmacist to find out if the patient was refilling prescriptions as prescribed). Regularly refilling prescriptions has been linked in studies of HIV-positive people to relatively high rates of adherence.
- 14% would ask patients to bring in their pill bottles and count the number of unused pills.
- 3% would consider asking a laboratory to assess the amount of PrEP drugs in a patient's blood sample.
Most doctors would assess adherence every three months. However, 11% of physicians disclosed that they would not assess adherence.
Common reasons for physicians discontinuing providing PrEP were as follows:
- the development of any signs, symptoms or laboratory test results suggestive of toxicity
- when the patient's adherence falls below 80%
- if behaviours that placed people at high risk for becoming infected with HIV decreased
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