{"id":8631,"date":"2018-02-25T18:42:20","date_gmt":"2018-02-25T23:42:20","guid":{"rendered":"https:\/\/blogs.nejm.org\/hiv-id-observations\/?p=8631"},"modified":"2018-02-28T12:43:39","modified_gmt":"2018-02-28T17:43:39","slug":"self-administered-post-exposure-prophylaxis-another-viable-option-hiv-prevention","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/self-administered-post-exposure-prophylaxis-another-viable-option-hiv-prevention\/2018\/02\/25\/","title":{"rendered":"Is Self-Administered Postexposure Prophylaxis Another Viable Option for HIV Prevention?"},"content":{"rendered":"

\"\"<\/a><\/p>\n

Most of the pivotal trials of pre-exposure prophylaxis (PrEP) have used daily therapy.<\/p>\n

The lone exception is the IPERGAY study<\/a>.\u00a0Men at high risk for acquiring HIV took two tablets of tenofovir DF\/emtricitabine (TDF\/FTC, Truvada) before sex, and one tablet the next 2 days.<\/p>\n

The strategy was highly effective in preventing HIV acquisition, and intermittent PrEP is endorsed as an option in France, where the study was conducted.<\/p>\n

(About that name — it stands for\u00a0Intervention Pr\u00e9ventive de l\u2019Exposition aux Risques avec et pour les Gays<\/em>. I have it on good word from the lead investigator that they can say it in French without smiling.)<\/p>\n

The main concern some have raised about the IPERGAY results is that participants had relatively frequent exposures (a median of 4\/month), enough so that sufficient tissue levels of TDF\/FTC could be maintained.<\/p>\n

But what about even less<\/em> frequent high risk exposures, say a few of times a year? Daily PrEP for these patients seems like overkill, and intermittent PrEP may not work. Might they benefit from a different prevention strategy?<\/p>\n

A group in Toronto just published a novel approach to these patients<\/a> — instead of giving them PrEP, they are recommending on-demand postexposure prophylaxis (PEP).<\/p>\n

(In the paper, they call it “PEP-in-pocket,” or “PIP,” but I don’t think we can tolerate another one of these single syllable abbreviations in HIV prevention that begins with “P.”)<\/p>\n

From 2013–2017, two clinical sites identified relatively low-risk individuals from those who were initially referred for PrEP.<\/p>\n

The preventive strategy consisted of prescribing a 28-day supply of TDF\/FTC plus dolutegravir, with instructions to start it as soon as possible if the patient had what they deemed to be an exposure that might transmit HIV.<\/p>\n

Thirty such people were identified. In the follow-up period, 4 of the 30 initiated PEP on their own, all doing so within 10 hours of the exposure. Each reported good adherence to their treatment, and were closely followed-up.<\/p>\n

All who started preventive medications were seen in clinic within a week for clinical evaluation\u00a0and blood work. There were no HIV seroconversions in 21.8 person-years of follow-up.<\/p>\n

Of course, the small size of the study, and its retrospective, non-comparative design hardly are sufficient to incorporate this strategy into guidelines.<\/p>\n

Nonetheless, there are several advantages to this on-demand PEP strategy. These include avoiding daily exposure to medications, lower drug costs, reducing emergency room visits, and still providing some preventive intervention, just in case. Individuals who start on-demand PEP multiple times can be transitioned to PrEP, which is what happened to 4 of the patients in this study.<\/p>\n

I look forward to hearing more about this approach — and I’d be saying that even if the senior author<\/a> weren’t a graduate of our ID fellowship program!<\/p>\n

(Nice work, Isaac.)<\/p>\n","protected":false},"excerpt":{"rendered":"

Most of the pivotal trials of pre-exposure prophylaxis (PrEP) have used daily therapy. The lone exception is the IPERGAY study.\u00a0Men at high risk for acquiring HIV took two tablets of tenofovir DF\/emtricitabine (TDF\/FTC, Truvada) before sex, and one tablet the next 2 days. The strategy was highly effective in preventing HIV acquisition, and intermittent PrEP […]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,4,8],"tags":[706,748],"class_list":["post-8631","post","type-post","status-publish","format-standard","hentry","category-health-care","category-hiv","category-patient-care","tag-pep","tag-prep"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8631","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=8631"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8631\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=8631"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=8631"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=8631"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}