Drs. Maxime Billick and Isaac Bogoch from the University of Toronto discuss the buffet of options available for HIV biomedical prevention!

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Febrile is produced with support from the Infectious Diseases Society of America (IDSA)

Hi everyone, welcome to Febrile, a cultured podcast about all things infectious disease.

We use consult questions to dive into ID clinical reasoning, diagnostics, and antimicrobial management.

I'm Sara Dong, your host and a MedPedsID doc.

Today, I have two guests from the University of Toronto.

First up is Dr.

Maxime Billick.

Hi, I'm Maxime.

I'm a newly graduated ID, I guess, staff, former fellow from the University of Toronto.

Maxime is a recent graduate of the ID program at the University of Toronto, where much of her resident research centered around post-exposure prophylaxis in pocket.

She is excited to start her master in public health this academic year at the T.

H.

Chan School of Public Health at Harvard University.

Hey, I'm Isaac Bogoch.

I'm an infectious diseases physician and scientist based out of the Toronto General Hospital and the University of Toronto.

Dr.

Isaac Bogoch is an associate professor at the University of Toronto and an I.

D.

specialist at Toronto General Hospital.

He focuses on tropical diseases, HIV, and general I.

D.

He works at the intersection of clinical medicine, epidemiology, public health, and policy, and he divides his clinical and research efforts between Toronto and several countries in Africa and Asia.

His work focuses on integrating HIV prevention strategies for marginalized communities and mitigating the impact of emerging infectious diseases such as COVID and impacts.

As everyone's favorite cultured podcast, I would love to hear, you know, a little piece of culture, something non medical that brings you happiness.

Sure.

I've been thinking about this for a while cause I listened to your podcast and I don't know if I'll think of something as punchy as I wanted to, but, um, I'm about to go to Maine with my whole big family, like my brothers and their kids and my parents and my partner.

And, uh, I used to go when I was a kid and, you know, we would catch crabs and play on the beach, and it's just really nice to be there as a big family and to see my nieces and nephews do that too.

Um, so I'm psyched for that and to eat lots of lobster.

That sounds like an awesome summer day.

It's a bit of a dream.

Yeah.

What about you, Isaac?

I'm a, I love traveling, but I've discovered being a tourist in my own city is wonderful and, uh, really looking at exploring different neighborhoods and aspects of Toronto from a tourist viewpoint and, uh, it's been a lot of fun doing that and I hope to continue doing that, uh, not just this summer but, uh, moving forward.

Excellent.

Well, any particular recommendations?

Say it's someone's first time in Toronto.

There's like the obvious big things to see and do, but, you know, I'm totally biased here, but when you scratch the surface, it's a huge city.

There's so much to do.

The music scene is just unbelievable.

And, uh, you know, there's obviously the big venue concerts, but these little venue, uh, shows in various parts of the city are just, are just remarkable.

And it's one of the most multicultural cities on the planet.

The food is unbelievable.

And, um, you know, you can go to various nooks and crannies in the city and eat in, uh, hole in the wall restaurants and have, you know, not just Ethiopian food, but southwestern Ethiopian food or northeastern Ethiopian food.

Like, it's just, the variety is, is unparalleled here.

We're very lucky to live here.

And I, I don't, I don't think we use our city as much or as well as we should.

There's lots to do.

And I'm having a lot of gratitude these days for living here.

Yeah.

I was going to say, there's lots of good eats in Toronto.

I've had a lot of great meals there.

Alright, so today we're going to flip our usual structure slightly.

We're going to talk more broadly about our topic first and then discuss a few almost rapid fire clinical scenarios towards the end.

So our focus today is going to be on HIV prevention.

Or more specifically PIP, which is post exposure prophylaxis in pocket.

And we are going to be using these abbreviations or terms.

So we're going to do our best to make sure we're defining the full name of what we mean when we're first using that abbreviation.

So back in 2021, you know, when we started Febrile, we did have a brief, uh, HIV starter pack of episodes that we called Fresh StART.

And we did speak a little bit about PrEP, but not really about PEP, post exposure prophylaxis or PIP.

So I'm actually going to start with that, you know, start quite broad with the question, what is biomedical HIV prevention?

What are the current types of options that we have in North America?

So maybe I'll throw that to you, Maxime.

Sure.

Yeah.

Thanks so much.

So when we think about biomedical HIV prevention, what that usually means is using medicines to prevent HIV.

Like we know that there's a lot of behavioral things that people can do.

People can wear condoms, people can abstain, people can choose to partake in lower risk activities that don't have as high a risk of transmission, but the term biomedical HIV prevention really refers to somehow getting some sort of medicine in your system to prevent acquisition of HIV.

The sort of mainstays of therapy for biomedical HIV prevention up until pretty recently was something called PrEP, you alluded to it, pre exposure HIV prophylaxis.

Usually, this is a two drug regimen whereby people take a pill every day to prevent getting HIV when they do have a potential risk encounter.

There's also something called on demand PrEP, or 2-1-1.

So if like someone's going, I don't know, it's a Friday night, they know they're going out, they might hook up with someone, they can take two pills of PrEP two to 24 hours before, one pill the next day, and then one pill the day after.

And the thought is that - well not really the thought - the evidence shows that that prevents against HIV, particularly in people who have penises or men.

Pretty excitingly, there are some new drugs on the market, specifically injectables.

So this is usually a one drug regimen and people get a shot, usually in the bum, and that is the up until like about a week ago, that was monthly.

Although there's some new evidence for a drug called lenacapavir in women, which is really cool.

It was just hot off the press this past Wednesday.

Yeah.

Yeah.

So this was like really hot off the press, but let's just say, you know, an injectable at a longer interval.

And then you guys, I believe in the States, correct me if I'm wrong.

We're in Canada.

So I think you have a ring that people with vaginas can wear.

That's not really super prevalent here, um, in Canada, but that's an option.

And then there's some research going on about, uh, implants.

So like the same way that there's like Implanon and Nexplanon for prevention of getting pregnant.

There's some research into that, but it's not actually out on the market yet.

So all of those are versions of PrEP, or pre exposure prophylaxis, before the risk encounter occurs.

Then there's something called PEP, or post exposure prophylaxis.

And that is, someone has a risk exposure that can be sexual, that could be, um, sharing needles, et cetera, and they go to care and they take a three drug regimen for usually about 28 days.

I think we're going to get into some of the benefits and limitations of these after, so I'm not going to jump into it just now, but I'll just say that usually people have to present to care after the fact, which can be a huge barrier to care.

And, uh, they take it for 28 days and then they stop.

And the newest kid on the block, which is, you know, a little bit more implementation focused is PIP or post exposure prophylaxis in pocket.

And then maybe I'll save that for Isaac to explain a bit down the road.

Yeah.

So, you know, I think a lot of people who listen to Febrile have at least some familiarity with PrEP, and/or are prescribing it frequently.

We know it works extraordinarily well for people who are at risk for HIV, but before we throw it over to Isaac, maybe you can quickly summarize those barriers that we often encounter when thinking about PrEP or pre exposure prophylaxis.

Totally.

So PrEP is pretty great.

It works really well for people who are at risk of HIV.

But most of the research has been in gay and bisexual men who have sex with men, and that's where we've seen the really striking benefits up until recently.

Some of the, like, there are multiple barriers.

It's an expensive medication, right?

So if people don't have coverage, if people have to pay out of pocket, it can be hundreds, if not thousands of dollars a month.

Um, it's taking a pill per day, so people have to remember to take the pill.

They have to take it around the same time every day.

There's potential side effects to taking medications.

The side effects are usually pretty minimal, but in some people, it's enough to stop taking the medication or to not want to take it at all.

Importantly, the 2-1-1 regimen, or PrEP on demand, only has evidence in men who have sex with men.

So we don't know if it gets into vaginal tissue as quickly or as well.

Also, in all of the studies, people were taking it like upwards of four times a month.

So they're taking pills in their system, four times three is at least 12 days out of a month, right?

About one third of the time.

We don't know how well it works for people who are having four encounters per year, right?

Like, are the levels in tissues as high?

We have no idea.

And so those are some of the biggest barriers, I think, to PrEP, you know, not to mention that you have to usually, you know, go see a doctor pretty frequently, usually every three months.

Um, there are some online options now, but it, you know, you still have to have access to the internet or to a computer or to a safe space to have these conversations.

Um, so I, I think that those are, some of the main limitations of PrEP.

Great.

Yeah.

So that's our PrEP bucket.

And now thinking about PEP, which has also had success, a lot of data out there.

Maxime started to refer to one of the big barriers of PEP, which is actually presenting to care.

Isaac, what are other things that you think about as far as limitations of, uh, what we could kind of call traditional PEP or post exposure prophylaxis?

Yeah.

Thanks for bringing that up, uh, Sara.

It's a good point.

And PEP is phenomenal.

It works really, really well.

We have decades of experience with it, but, you know, there are, it's not, for something that works so well, I think if you talk to people who deal with HIV prevention pretty regularly, I think many people would be frustrated in implementation.

And a lot of that is, uh, because of the, the, the barriers.

A lot of these barriers are related to accessing care, right?

First of all, the clock is ticking.

For PEP to really work well, you've got to start those medications as soon as possible, preferably within 24 hours, but usually within a 72 hour window.

That means people, A, have to recognize an exposure has occurred.

Some people might not, due to a variety of reasons.

B, you have to have access to medical care, usually an emergency department or an urgent care clinic.

And, again, we're thinking globally and locally, there are significant barriers to access to care.

C, once you, let's say you, you, you recognize there's exposure and you make it to care.

Well, now you're in care.

First of all, you have to know that there's an option available to prevent HIV.

So there's a community level awareness, which I think is significantly lacking.

And then D, the clinicians, whoever's seeing you, has to know that there are pills that can work.

And then E, you have to have access to those pills, and there's tremendous costs associated with them.

So, there's a lot that goes into making PEP work well.

Then on top of that, let's just think about a practical scenario.

Someone has, uh, condomless anal sex.

Some poor person is raped.

Some person shares injection drug paraphernalia.

You know, very few people want to go wait in an emergency department at four o'clock in the morning for four hours to talk to a total stranger in a crowded, busy place where everyone can hear about the rape they just survived, the anal sex they just had, or the needle they just stuck in their arm.

So there's also, I think, that is an enormous to, uh, appropriate PEP rollout.

Having said that, if people access the drugs, if they access it in a timely manner, if they take the medications, we just don't see HIV acquisition when, when PEP is used.

So there are better ways to use PEP, which I think is a good segue into what we're going to talk about next.

Yeah, you're making my job pretty easy.

So that's what we wanted to do is spend the bulk of this episode talking about PIP.

You know, where that idea came from, how it's different from traditional post exposure prophylaxis and you know, a little bit on logistics of implementing this.

So maybe I'll start there.

What is PIP and how is it different from traditional PEP?

Yeah, so PIP stands for PEP in pocket or post exposure prophylaxis in pocket.

And really what this is, is an additional tool to prevent HIV.

Really where we see this working best is for people who have anywhere from zero to four potential HIV exposures per year, so very infrequent exposures per year, and we proactively identify who these individuals are.

These exposures may or may not be unexpected, and we proactively provide them with guideline approved post exposure prophylaxis regimen, the full 28 day course.

We obviously are aware that guidelines differ in different parts of the world, that's why instead of saying use this drug or that drug, we just say guideline approved PEP regimens, and the important point is the full 28 days.

Because an exposure hasn't yet occurred, we have a bit of a gift of time.

And that means we can work with whatever local health or support networks are available to ensure people are able to access those 28 days.

And then we basically say, hey, here's 28 days of pills.

Put this in your sock drawer and let it be.

And live your life.

And you know, in the scenario where there's a potential HIV exposure, individuals do not have to go seek immediate care at an urgent care center or an emergency department.

We treat adults like adults, they have the pills, they know exactly what to do, there's virtually zero barriers to this whatsoever, you just go to your sock drawer, start one pill once a day, usually we use a one pill daily regimen these days, you have the full 28 days, and we say listen, on a much less urgent basis, hopefully within the first week, but you

know, on a much less urgent basis, come into the clinic, let's do some baseline screening tests, make sure everything's okay, let's have a quick chat, make sure everything's okay.

But really, this proactive identification of people with very low frequency HIV exposures will have much more timely access to antiretroviral medications.

And we basically alleviate any need to seek urgent medical care, which we know, as we just talked about, is a major, major barrier to care.

Yeah.

And is there anything else from a, you know, logistical or barrier perspective that either of you want to mention or maybe things that you talk about when you meet patients and are counseling them for the first time?

Yeah, absolutely.

I'll let Maxime jump in there.

I'd love to hear her thoughts, but you know, this was really started in about 20, late 2013, early 2014.

So PrEP, was in its infancy, globally, and we actually started the first PrEP program in Canada at the Toronto General Hospital.

And we were rolling out PrEP very early on, but, you know, between myself, a wonderful nurse, Pauline Murphy, and a very dedicated, wonderful social worker, Andrea Sharp, you know, we were clearly providing PrEP to people who were at high risk, but we didn't really have any good options for people at much lower risk, uh, who had much, sorry, much fewer frequency exposures.

And that's where PIP was born, is putting a few heads together and finding creative solutions to basically what was a large vacuum in HIV prevention.

We had good tools at that time, we continue to have wonderful and effective tools to prevent HIV and those with greater risk exposures, but there are a lot of people that, you know, probably shouldn't be taking one pill once a day, or an injectable, or even where 2 1 1 isn't, isn't appropriate, where

PIP would really fit in, and, uh, and so we started implementing this and studying it way back in late 2013, early 2014, and it, it found a niche.

Now again, is PIP going to you know, roll out globally and stop HIV, like absolutely not.

It's just an additional tool and it provides more options available for patients and clinicians, uh, because we know people don't take a linear path through life.

Their risk, their HIV risk is not linear through life.

Some people are at very high risk for HIV and are appropriately on, on PrEP, but others, you know, maybe get into a stable monogamous relationship or something happens where they're no longer as high risk as they once were, but they still are not zero risk and PIP provides a really good tool to prevent HIV in those individuals.

Maintains autonomy and agency over their care.

Immediate access to antiretroviral medication should an exposure occur.

Sort of like one of those, you know, in emergency break glass.

Here's an option available for you.

And then maybe just from a, um, like more, uh, detailed perspective, you know, in addition to prescribing people PIP and then asking them to give us a call and to come back to clinic, you know, a week or two later for testing, we do baseline testing, similar to how you would do

baseline testing for PrEP, or in a situation like, you know, PEP in the emergency department, so, you know, we'll do a CBC, creatinine, liver enzymes.

We screen for sexually transmitted infections, gonorrhea and chlamydia in the throat, rectum, anus, you know, depending on people's sexual practices or everything.

I usually just do everything.

Uh, syphilis serology, I don't You know, people can not always tell you everything.

We, you know, routinely screen for HIV, and then we screen for hepatitis A, B, and C, and we ensure vaccination to A and B if they're non immune, and then don't forget doing some pregnancy testing.

I don't always think of that as an internist, but it's always a good thing if you have people with uteruses coming to see you.

And then, you know, if people have exposures and use their PIP, then we'll see them, you know, in short term interval follow up.

Otherwise, we tend to see them about every six months just to do routine testing and to make sure that PIP is still right for them.

So as Isaac mentioned, you know, people's risk changes throughout their lives and their circumstances.

So, you know, if they're having a lot more, for example, sex or HIV risk encounters, and they found that they've actually used PIP three times in a row, then maybe it's no longer the best modality for them.

And we can talk about switching to other modalities.

Yeah.

So, you know, along those lines, when you're talking with patients, how do you make sure that PIP is the best modality for them?

You started to talk a little bit about who, who might be the best candidates, but what are things that you may hear from a patient that tell you, maybe we should consider changing the method of HIV prevention that we're using?

Totally.

So if people are having more than 4 exposures or potential exposures per year, to us that says, you know, hey, maybe this isn't quite working for them because then they're taking, you know, post exposure prophylaxis, 3 drug regimen for about 4 months a year.

At that point, a version of PrEP is probably more appropriate.

If they're not tolerating the medications for whatever reason and we would need to potentially switch them.

You know, also, of course, patient preference.

So if they're like, you know what, it's, it makes me really anxious that I have a potential risk exposure.

I know I'm not having many, but I just want to know that I'm totally protected all of the time, et cetera, et cetera, you know, then we'll have a conversation with them about that.

So really like the point of of PIP is to just have another tool in your toolbox to offer patients.

Um, and it's going to be an ongoing discussion and just the same way that we put a lot of other medications in the hands of patients.

So, for example, people will have pill in pocket beta blockers for, you know, anxiety or for palpitations.

I don't know about in the States, but in Canada, you can now get single dose fluconazole for vaginal yeast infections over the counter.

Plan B in a lot of places is available, you know, with just a pharmacist consultation.

So, you know, we trust patients to do that, to take those medications.

I think that we can trust patients with enough education to take their PIP at an appropriate time.

Yeah.

Yeah.

Uh, Maxime, I'm, I'm with you all the way.

That's, that's so, so well said.

I've been calling this the buffet approach to HIV prevention.

And for starters, I love buffets.

But secondly, you know, the buffet is really, here are all the options available.

Here is everything that we have.

We have injectable PrEP, we've got 2 1 1, we've got daily PrEP, we've got TAF FTC, we've got TDF FTC, we also have PIP, sort of in the middle, and at the lower end of the spectrum, we have nothing.

You can choose to do nothing as well.

And I think what we do very poorly in HIV prevention is reassess risk at every clinic appointment.

And we should really be doing that with all of our patients at all of our clinical encounters is reassessing risk.

Risk is not static.

Of course, it's dynamic.

And we have more tools in our toolbox to offer patients, and we can provide a much more granular approach to HIV prevention in 2024 compared to prior years.

So it's remarkable.

And, and as you guys were chatting about earlier, like the, uh, the further options with injectables are coming through the pipeline, this is a really exciting time.

So, you know, every time someone comes in, you know, obviously we, we, we talk about, you know, how's it going, drug effects, uh, you know, tolerance, et cetera, screening, but, but I think it's extremely important to talk about, are you on the right drug?

or the right program for now and for your near future.

And most of the time the answer is yes, and we just carry on carrying on with with PrEP or whatever someone is on.

But a lot of the time the answer is no.

And again, this is the buffet.

Here are all the options available.

You're always welcome back to the table.

You can take whatever you want.

Uh, let's have an evidence based, patient centered approach.

Let's listen, as I love how Maxime pointed out, listen to patient preference as well.

That drives a lot of this, but we can enable smart decision making by giving people the options, letting people know what the options are available, and then supporting them in their choice.

And the other important thing to do is to remind people no decision is set in stone.

Of course, we tell people flat out.

Of course, risk is dynamic.

You might be on PrEP for a little while.

If you ever want to change to PIP, come on in.

No problem.

Happy to, happy to put you on PIP if you're on PIP and you're having more frequent exposures or you might be anticipating having more frequent exposures.

Let's move you back to PrEP.

And in fact, in some of the research that we've been publishing over the last few years shows, you know, about a third of our patients on PREP have moved to PIP at some point in their life.

Life, a third of our patients on PrEP, on PIP, have transitioned to PrEP at some point.

So there, it's, it's really helpful to have these, these tools available.

And one other key point, you know, the WHO just released their HIV prevention, their post exposure prophylaxis guidelines, literally this month, July of 2024 at the IAS conference in Munich, and they've integrated PEP in pocket into those guidelines, which is pretty remarkable.

And they, they talk about how, uh, PIP might be a useful tool for, for some people.

And these are exactly the scenarios that we're discussing.

So I think we're going to start to see this roll out much more broadly given its international exposure and integration into WHO post exposure prophylaxis guidelines.

And exactly like Maxime said, it's.

It's another tool in the toolbox.

It gives more options to patients.

It gives more options to providers to offer their patients.

And I think it really helps for people who have a dynamic risk or even people have a static low frequency risk as well.

Yeah.

And so we're going to move into some of those clinical scenarios in just a second about picking from the buffet.

But one last thing before that is how do you switch people from PIP to PrEP and vice versa?

Sure.

Yeah.

So.

Let's talk about PIP to PrEP first.

If you're going from PIP to PrEP, you would do it, you know, if people are familiar with transitioning anyone from post exposure prophylaxis to PrEP, it's essentially the same.

So you want to, you want your patient to continue and to complete their full 28 day post exposure prophylaxis or PEP course, um, you're going to do repeat testing, right?

Make sure that they didn't acquire HIV at the end of the, at the end of the course.

And then you're going to have them start PrEP right away.

So, and that would be switching from a three drug regimen usually to a two drug regimen usually.

Um, and then they would just continue on PrEP, you know, as, as one does.

Going the other way around, you know, you can kind of switch or stop at any time.

So, if someone's on PrEP and they feel like they don't really need it anymore, they're not having any high risk encounters, they can just stop cold turkey.

And again, it's important to tell people usually to stop and not sort of take intermittently.

And then when they do have a potential risk exposure, um, to start their PIP, you know, as soon as possible and within 72 hours.

So again, pretty simple, um, the follow ups will obviously be a little bit different.

Usually PrEP follow up is about every three, maybe every four months, whereas PIP follow up, if people are not using their PIP, then it's just every six months.

If they do use their PIP, then, you know, we tell them to come in within a week or two of using it.

All right.

Okay.

So we're going to talk through a few clinical scenarios.

I'll go back and forth.

I'm going to start with you, Maxime.

These will be just quick, you know, one to two liners.

And then you can share with us what your thought process is for picking which item from the HIV prevention buffet.

All right.

So first we have a 25 year old male.

He is a man who has sex with men, goes out about two weekends per month, and often has both receptive and penetrative anal sex with people he does not know.

What is the best biomedical HIV prevention modality for him?

Sure.

So just picking out some key points here.

So, you know, younger man, MSM, having some higher risk encounters, particularly with the receptive anal sex, going out, hooking up with people about two times per month.

Um, so that is definitely more than four times per year.

Um, so PIP actually isn't appropriate here just based on his frequency of encounters, and I would encourage him to use, um, PrEP.

There are multiple different types of PrEP that would be appropriate in this case.

So, again, he's going out pretty frequently, so daily PrEP, I think, would be something that I would try and advocate for, or if he's open to it, injectable PrEP.

Um, some of that will depend on how often he wants to come in.

If he likes to take, you know, he's okay with taking pills versus prefers injections, etc.

2 1 1 or on demand PrEP could also be appropriate here.

He's having lots of encounters, so I might try and, you know, see if he's open to the daily PrEP.

But again, if he can't or if it's too expensive or whatnot, 2 1 1 would certainly be appropriate as well.

Excellent.

Okay, Isaac, you're up for the next one.

Sounds good.

A 36 year old woman who engages in sex work presents to a sexual health clinic for symptoms of a sexually transmitted infection.

She routinely uses condoms, but says that this infection was acquired in the context of a non consensual, condomless sexual activity at work.

What are you thinking about here?

Yeah, just taking a step back, obviously this is an awful scenario.

I know we're talking about HIV prevention, but you know, we still have to recognize this as a sexual assault and you would want to use every resource available to ensure psychosocial and other medical support for, for this poor individual, and, you know, honing down into the weeds and just focusing on HIV prevention, which, of course, is one important piece of a much larger puzzle.

You know, I think this is, this is a scenario where you would really discuss with her, what her preferences are, and, you know, as we chatted about the buffet approach, you know, if this is someone who is truly only having a 0, 1, 2, or 3, or 4 exposures, potential exposures to HIV per year, meaning condoms are used appropriately and, and, um, consistently, both as part of sex work

and out of sex work, then, you know, Uh, PIP may be a very reasonable option for, for her, as in, here's a wonderful and guideline approved approach to significantly reduce the risk of, of HIV.

She would not have to go into an urgent care center, a sexual assault center, an emergency department to initiate, rapidly initiate antiretroviral therapy to prevent HIV infection.

She could self initiate it as soon as possible and usually, easily within a 24 hour window should she have access to those medications like PIP provide.

So I think PIP could be a good option.

But again, like, like Maxime was saying earlier, some of, we can help walk people through various scenarios and enable and edu enable them to make smart decisions for themselves.

If this is an individual who said, you know what, I'd just be more comfortable on PrEP, I'm not the gatekeeper to the healthcare system and I would certainly support her in that decision as well.

And discuss the various merits and drawbacks and various types of PrEP for her preference.

But certainly, this is an individual where PIP could, could, would be discussed and presented as an option.

And, you know, quite frankly, we do follow people in our clinic who sadly have been in this very, uh, this exact scenario who are on PIP and who like it because it gives them immediate access to HIV prevention should they need it.

And then, you know, God forbid a situation like this happens, they can also seek care with a provider that they're comfortable with and they don't have that urgency of seeking care within a 72 hour window because their HIV prevention has been initiated.

Thanks.

All right.

Bringing it back to you, Maxime.

A 47 year old man taking HIV pre exposure prophylaxis, or PrEP, presents to a primary care clinic for a routine follow up visit.

He is considering entering a monogamous relationship with a male partner, but is uncertain if he may have very infrequent sex with other partners.

He's wondering about whether to discontinue PrEP.

What type of conversation would you guys be having?

Yeah.

Thank you.

So this is actually a scenario that we see not infrequently, right?

As we've said multiple times throughout this chat, like, people's risk is dynamic and changes.

And sometimes, like, we don't always know in advance what a future relationship is going to look like and when people are going to, you know, open it up to having sex with other partners or not.

And so, what I hear in this situation is someone who is, you know, thinking about being or is currently being more monogamous, but there are the potential for risks in the future.

And they seem a little bit nervous, perhaps like that they want to protect themselves.

So, you know, a couple of things here is, oftentimes when I'm in these types of situations, I'll, again, explain the buffet of options that we have to patients and see if something sort of lands with them.

Because the truth of the matter is that people don't always tell us as clinicians or as providers how much sex they're having.

So if somebody If someone wants to continue on PrEP, maybe not this guy, but if someone wants to continue on PrEP, or they think it's right for them, you know, then it's my job to help facilitate that, not necessarily to ask, um, all of the details of their sex life, right?

In this particular situation, you know, it sounds like, I think this patient is likely going to have very infrequent sex with other partners, and I think that PIP is a reasonable option, so I'd certainly offer that.

Another potential one is 2 1 1 or PrEP on demand.

It really depends if it's the type of thing that he is going to anticipate in advance.

You know, is it like Okay, around pride or twice a year, like we're going to go to the bathhouse and I know that I'm going there and that's sort of the purpose or is it like, oh, it's going to happen more randomly and I'm not sure when it will happen.

And so in those cases, PIP is more, um, appropriate, I think.

All right.

And Isaac, you're going to round us out.

This is our last one.

Uh oh.

Home run.

All right.

So we have a 50 year old heterosexual woman who is traveling to South America on a three week trip.

She might have sex while she's traveling.

She usually wears condoms, but has had instances when intoxicated when she hasn't.

She doesn't want to have to go to a local hospital or health clinic to get PEP.

In fact, she tells you she probably just wouldn't and would ignore things until she got home.

So what recommendations and counseling do you have for her?

Yeah, Sara, this is like the underhand pitch right over the plate, right?

Like, so here's someone who probably won't have an exposure to HIV because she uses condoms regularly, but oops, once in a while she does.

Like, this is a no brainer.

You give this person 28 days of a guideline approved PEP regimen to take with her on her trip.

If she needs them, great.

She's got immediate access to them.

If she doesn't need them, great.

They sit in her bag and, uh, and maybe she takes them on her next trip, you know, uh, but, uh, this is, this is a good scenario.

Here's another potential scenario as well.

Let's talk about people who work in our field, clinicians, who do work overseas as well.

And they may have an occupational exposure or a non occupational exposure and require PEP, while they're working in a part of the world where there's limited access to healthcare.

This is, this has been done in the past, mostly for occupational exposures, but we're really moving this into the non occupational exposure realm.

And, uh, and have some significant success.

Usually, you know, depending on where you are in the world, Biktarvy is the drug of choice, safe, one pill once a day, pretty, pretty widely available in many, of course, not in all places.

Obviously, I appreciate there's different guidelines elsewhere.

Some places are using, you know, You know, dolutegravir based regimens for uh, women who may be pregnant in the in the near future or are currently pregnant.

Others are using Biktarvy in these scenarios as well.

So again, I think the best way to frame it is whatever your local guidelines suggest are the drugs that that you should be sticking with.

But the key is the full 28 days are provided so that people have truly few to no barriers to initiating antiretroviral medications should an exposure occur.

Thank you both so much for joining today and, um, tackling this topic.

I'll open it up here since we're wrapping up to just see if there's any take home points or items that you want to reinforce for our listeners.

Maybe I'll go first and then let Isaac, you know, close it out.

We've probably sort of hammered this home multiple times, but really making sure that people understand that PIP is one option of many, and that a lot of this ends up being relationship building with the patient in front of you, seeing what is best for their current situation, for their potential future situation.

And recognizing that this applies to a lot of different types of patients, right?

It applies to the person who's traveling abroad twice a year.

It applies to the person who was, you know, on PrEP and used to be having a lot of sex and now is in a monogamous relationship, but might have infrequent sex with another partner.

It can apply to rural populations and people who have limited access to hospitals or no urgent care centers open in the middle of the night, um, so it really applies to different types of people and patients, and I would just encourage anyone listening to this podcast to think about, you know, the patients they serve and how this might sort of fit into their lives and their prevention strategy.

Mine is, uh, pretty straightforward.

I, you know, I think largely HIV prevention strategies have been ruled out.

Pretty, pretty well, pretty effectively in many parts of the world.

Obviously, there's room for improvement.

I think one of the big areas we can do better in is constantly re evaluating the current and near future HIV risk of our patients, and we do that by talking to them and asking them, you know, what is your current and near future risk?

And how many exposures are you having?

And I think sometimes people just get stuck on, on PrEP.

And, and most of those people still probably should be on PrEP, but there are certainly many who who shouldn't be on PrEP, where there's another HIV prevention modality like PIP, which would be better suited.

And, and just appreciating the dynamic nature of risk, and now having more tools available to have the most appropriate HIV prevention modality for the, for the, for the patient that's, that we're trying to serve.

I do like that concept of the buffet because everyone likes buffets and we have more options on the buffet and you can always come back to the table and take another option when your tastes change.

Uh, and I think that's a good analogy that I've started to use more.

But, uh, yeah, I think, like Maxime said, I really hope people are aware that there's more options available to them.

It's endorsed by the WHO guidelines released July of 2024 and, uh, I think we can really help serve the, serve our communities better by ensuring they're aware of, of the various options available to them.

Thanks again to Maxime and Isaac for joining Febrile today.

We will put some links to some great resources that they've worked on as well as the most recent WHO guidance.

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