Physicians debate best management strategy for patient at risk for HIV exposure

In a new Annals ‘Beyond the Guidelines’ feature, two physicians experienced in HIV antiretroviral pre-exposure prophylaxis (PrEP) debate how best to identify those patients who might benefit from PrEP, how to decide what regimen to use, and how to monitor therapy. All ‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine.   

Despite advances in treatment, HIV infection remains an important cause of morbidity and mortality, and more than 30,000 new cases are diagnosed in the United States each year. Several interventions have traditionally been used to prevent HIV transmission, but these vary in effectiveness, and there are challenges in their implementation. Both the CDC and the USPSTF strongly recommend the use of HIV PrEP for persons at risk. However, the implementation of PrEP in clinical practice has been variable, especially among patients underserved by the medical system and marginalized by society. Fewer than one-third of persons in the United States who are eligible for PrEP currently receive it. 

BIDMC Grand Rounds discussants, Douglas Krakower, MD, Associate Professor of Medicine at Harvard Medical School and a member of the Division of Infectious Diseases at Beth Israel Deaconess Medical Center and Jessica L. Taylor, MD, Assistant Professor of Medicine at Boston  University School of Medicine and Medical Director of Faster Paths to Treatment at Boston Medical Center,  recently debated the case of Ms. S, a 30 year-old woman with substance use disorder who is at risk for HIV infection and has intermittently received PrEP.  

In his assessment, Dr. Krakower recommends that Ms. S receive PrEP given her high risk for HIV infection. He also recommends injectable cabotegravir because of psychosocial challenges interfering with persistent daily pill use. Dr. Taylor recommends that Ms. S should be offered PrEP where she already accesses addiction treatment, harm reduction, and other services. She recommends that Ms. S receive daily oral TDF/FTC, as it is the only medication with evidence for HIV prevention among both people who inject drugs and people at risk via vaginal sex. Dr. Krakower believes that robust support from an interprofessional health care team would be essential to maintain adherence to any PrEP method. In addition, he would recommend counseling on safer sexual and injection behaviors, as well as treatment of HCV infection after resolution of her acute medical issues. Dr. Taylor suggests that in the future, a switch to cabotegravir could be considered, acknowledging the gaps in evidence for parenteral exposure. She also recommends other HIV prevention interventions, including continued methadone treatment, provision of condoms and sterile injection equipment, and the availability of STI testing and treatment, should be optimized. 

A complete list of ‘Beyond the Guidelines’ topics is available at www.annals.org/grandrounds. 

Media contacts: For an embargoed PDF, please contact Angela Collom at [email protected]. For an interview with the discussants, please contact Kendra McKinnon at [email protected].