What Happens When You Stop Taking Prep and Start Again
September thirteen, 2020
4 min read
Q&A: What clinicians should know nearly starting, stopping and restarting PrEP
Source/Disclosures
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Disclosures: Rutstein reports no relevant fiscal disclosures.
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The need for HIV PrEP fluctuates as risk behaviors change. In a recent viewpoint published in The Lancet HIV, researchers reviewed electric current guidelines and the clinical implications of starting, stopping and restarting the daily medication.
Healio spoke with ane of the authors, Sarah Eastward. Rutstein, Medico , an internal medicine specialist at the University of North Carolina, Chapel Colina, to discuss what clinicians should know near safely discontinuing PrEP, dosages for starting or restarting the medication, and the take chances behaviors that require patients to reinitiate handling.
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Q: When is it safe for a patient to discontinue PrEP?
A: The simple answer is you can stop taking PrEP when you lot are no longer at risk for HIV infection. Intuitively, just honestly, agreement when information technology is safe to end PrEP is far from simple. A few examples I requite to my patients would be if they fit into the post-obit categories: if they are in a monogamous serodiscordant relationship and their HIV-infected partner is virally suppressed; if they are in a monogamous seroconcordant relationship; if they are able to consistently and correctly use condoms; or if they are abstaining from all sexual activity. Some guidelines advocate that if the person on PrEP has been using daily PrEP, they go on taking PrEP for 28 days later on their last exposure before stopping this is extrapolated from the postexposure prophylaxis guidelines, and the need for a month of PrEP after final HIV exposure is an area that requires further research. Other guidelines (CDC, International AIDS Guild, the British HIV Association, etc.) recommend taking PrEP for 7 to 10 days after the final exposure. For men who accept sex with men who are using "result-driven" or the "2+ane+1" PrEP dosing strategy, virtually guidelines abet connected use of PrEP for 2 days after their last sexual encounter. I think one of the major challenges to safely stopping PrEP is existence able to predict how long a catamenia of reduced HIV risk might continue HIV risk is dynamic. A fundamental aspect to safely stopping PrEP is having a plan for how and when a patient needs to consider restarting PrEP.
Sarah Due east. Rutstein
Q: What is the difference between risk perception and risk behavior?
A: Risk perception is how a person perceives their own personal risk, whereas risk behaviors are the bodily actions (eg, sex without bulwark protection, multiple sexual partners of unknown HIV condition, etc.). Numerous studies have demonstrated that our perception of run a risk frequently does non align with our actual adventure behaviors. So, in the context of HIV, a person may perceive themselves to be at low or no chance of acquiring HIV, whereas their actions are, in fact, those that are commonly associated with increased HIV acquisition adventure. The reasons for this misalignment are multifactorial but have important implications for PrEP uptake and PrEP persistence.
Q: What practise clinicians need to know about PrEP dosing for a patient who is discontinuing the medication?
A: I think this is a moving target, and guidelines are evolving in terms of how long a person should proceed to have PrEP later their final potential HIV exposure. At this point, when starting or stopping PrEP, one of the key things to know is what kind of sex your patient is having. Near guidelines concur that for patients who are taking PrEP for whom their HIV acquisition adventure is via receptive anal sex and they are employing an event-driven PrEP strategy, patients should go on taking PrEP for 2 days after their concluding exposure. If the risk of acquisition is via vaginal sexual practice, guidelines vary between 7 days and 28 days subsequently the last potential HIV exposure.
Q: When should a patient restart PrEP ? Is the dosing different for someone initiating PrEP for the first time and someone restarting PrEP ?
A: At this point, the indications for restarting PrEP are identical to those for someone who is initiating PrEP for the first time. Generally, this includes HIV-negative persons who are at substantial adventure of acquiring infection. The specifics are going to vary past region and subpopulation HIV prevalence but typically include men who have sexual activity with men, transgender women, people with HIV-infected partners who are non virally suppressed and other groups at increased chance that may include persons with contempo sexually transmitted infections, sexual practice workers or persons who inject drugs. The side by side part of answering the "when to (re)start PrEP" question is how long before a potential HIV exposure should PrEP be started in order to confer protection. Much like how long to continue PrEP after the last HIV exposure, the lead fourth dimension for achieving protective PrEP levels is an surface area of ongoing inquiry. For the about function, the evidence and respective guideline) hold that information technology takes longer to accumulate protective levels in cervicovaginal tissues than in rectal tissues. The so-called "event driven" (or "on-need" or "2+1+1") PrEP use strategy is likely an effective option for men who have sex with men, in which starting PrEP involves taking 2 pills before high-hazard anal intercourse, and so one pill a 24-hour interval for the 2 days following this potential exposure. For heterosexual women for whom their risk of HIV acquisition is through vaginal sexual activity, some guidelines suggest that a 7-day atomic number 82-in time of daily oral PrEP would be protective, whereas others suggest needing as many every bit xx days of daily oral PrEP to accumulate sufficient protective drug levels. I remember the information are leaning more toward a shorter (ie, 7-day) menstruum. There is no difference in PrEP dosing between someone initiating PrEP for the first time and someone restarting PrEP.
Just equally HIV risk changes over time, and then, likewise, can we anticipate that PrEP utilise will change get-go, end and restart. Patients, providers, and policymakers will need to develop strategies to help keep people on PrEP (with good adherence) when they need it, and safely navigate PrEP discontinuation when the drugs are no longer needed.
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Source: https://www.healio.com/news/infectious-disease/20200911/qa-what-clinicians-should-know-about-starting-stopping-and-restarting-prep
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