Prescribing PrEP in general practice: What GPs need to know

The availability of pre-exposure prophylaxis (PrEP) on the Pharmaceutical Benefits Scheme (PBS) represents a breakthrough in ending the transmission of HIV in Australia.
 
‘PrEP is a game changer when it comes to HIV prevention. It is critical to achieving our goal of virtual elimination of new HIV infections by 2020,’ Victorian Minister for Health Jill Hennessy said.
 
‘This is a great – albeit long overdue – win that makes this ground breaking drug more affordable and accessible through local GPs.’
 
Dr Vincent Cornelisse, a GP and sexual health physician who has been involved in PrEP research since 2014, told newsGP that one of the most important things for GPs to consider is the need to thoroughly assess patients before they are considered for a PrEP prescription.
 
‘The important points are: who do you give it to and who don’t you give it to? What do you need to check before you give it to someone, and what do you need to check on an ongoing basis?’ he said.
 
There are Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) has a number of resources available for GPs and patients, including the Australian PrEP guidelines and a two-page ‘how to’ guide designed to assist healthcare professionals on starting someone on PrEP.
 
Eligibility criteria
Dr Cornelisse recommends GPs familiarise themselves with available information in order to help them start the conversation with the patient sitting in front them, to discuss whether they are at significant risk of HIV and should go on PrEP.
 
‘The ASHM guidelines are intended for clinicians when they’re talking to a patient, to get an idea of their HIV risk and determine whether that patient could benefit from going on to PrEP,’ he said.
 
While many have traditionally viewed men who have sex with men as those most at risk of contracting HIV, that risk extends to many other patient demographics.
 
‘People who have a past history of syphilis, people who use methamphetamines, people who have rectal chlamydia or rectal gonorrhoea. The ASHM criteria go into a bit more detail trying to work out someone’s HIV risk,’ he said.
 
‘It’s important for clinicians to understand the eligibility criteria and understand that they can be useful when talking to a patient who may have an STI [sexually transmissible infection], or may use methamphetamines on a regular basis but they’re not necessarily asking about PrEP.
 
‘Those patients who may not be aware that they have an HIV risk, that’s where I really think the eligibility criteria is useful and can be a reminder for the clinician to ask, “Hey, you do actually have an HIV risk, have you heard about PrEP? Do you think you should start PrEP?”
 
‘There is a place for clinicians to actively discuss PrEP with patients who are at risk of HIV, rather than just relying on patients coming to them asking about PrEP.’
 
Dr Cornelisse suggests asking these questions in a sensitive manner to avoid any awkward discussion and cement concern as a treating GP.
 
‘Most people are pretty receptive to an expression of concern,’ he said. ‘In the end it comes from the clinician having a concern that their patient may have a risk that is currently not being managed, and offering a way to manage that risk.’
 
Despite the significant benefits of a breakthrough drug such as PrEP being listed on the PBS, there are still some obstacles to its availability. For example, certain populations may still have trouble accessing PrEP, such as people in remote Aboriginal and Torres Strait Islander communities, where there is significant HIV incidence.
 
Barriers to access also exist for people without Medicare cards, including international students.
 
‘We have a lot of overseas students [in Australia] and they might find it a bit difficult, as PrEP may or may not be covered by their overseas health insurance,’ Dr Cornelisse explained.
 
‘The other groups that may not access PrEP even though they may benefit from it would be people who are not engaged in medical care, who don’t have a regular doctor.
 
‘Also men who have sex with men who are not gay-identifying; they may not be linked into the LGBTQI community and they may not be aware that PrEP is a thing and may also not be cognisant of their own HIV risk.
 
‘So they may not seek PrEP even though they are at risk of HIV.’
 
The other side
Education for healthcare professionals is available to assist in screening for eligibility and prescribing of PrEP, but Dr Cornelisse stresses it is also important to be aware of who should not go on PrEP.
 
‘Probably the most important group are people who are already HIV-positive,’ he said. ‘So it’s essential that clinicians make sure they do an HIV test before they give someone a prescription for PrEP.
 
‘If someone is HIV-positive and they start PrEP, then the risk is that the HIV virus can become resistant to the PrEP medication, which would then limit their treatment options down the track. It doesn’t always mean that HIV can’t be treated, but it would reduce their treatment options.
 
‘When assessing eligibility for starting PrEP, it’s very important that the person has an HIV test, as well as having their kidney function checked, because PrEP can also affect kidney health.’
 
Dr Cornelisse also outlines the fact that, although 99% effective in HIV risk-reduction, PrEP does not protect against other STIs and becomes less effective in HIV prevention if doses are missed.
 
‘It’s really important for clinicians when they are prescribing PrEP to tell the patient that they don’t miss doses,’ he said. ‘And to explain that PrEP doesn’t protect from any other STIs, so it is important that people come back on a regular basis to have STI screening.
 
‘It is recommended that people on PrEP have an HIV test, a kidney function test, and a sexual health screening every three months.’

ASHM pre-exposure-prophylaxis PrEP