A 27-year-old man comes to the office to discuss HIV prevention. One of his sexual partners is an HIV-positive man who intermittently adheres to antiretroviral therapy, and the patient also has sexual encounters with men of unknown HIV status. The patient does not reliably use condoms due to loss of sensation during intercourse. He is concerned about his risk of HIV infection and is interested in the use of antiretroviral therapy or pre-exposure prophylaxis (PrEP) to prevent contracting the disease. The patient has had no recent fever, weight loss, rash, or malaise. He was diagnosed with gonococcal urethritis 3 months ago and was treated with antibiotics; he has no other medical history. The patient occasionally uses intranasal cocaine prior to intercourse and drinks a few beers on weekends. He does not use tobacco or injection drugs.
The patient's vital signs are within normal parameters, and physical examination is significant only for diffuse tattoos over the upper extremities. Serum chemistry is normal, and viral hepatitis screening is positive for hepatitis C IgG antibody alone. HIV testing is negative. After careful discussion about safe sex practices, which of the following is the most appropriate next step regarding PrEP use in this patient?

Question

A 27-year-old man comes to the office to discuss HIV prevention.  One of his sexual partners is an HIV-positive man who intermittently adheres to antiretroviral therapy, and the patient also has sexual encounters with men of unknown HIV status.  The patient does not reliably use condoms due to loss of sensation during intercourse.  He is concerned about his risk of HIV infection and is interested in the use of antiretroviral therapy or pre-exposure prophylaxis (PrEP) to prevent contracting the disease.  The patient has had no recent fever, weight loss, rash, or malaise.  He was diagnosed with gonococcal urethritis 3 months ago and was treated with antibiotics; he has no other medical history.  The patient occasionally uses intranasal cocaine prior to intercourse and drinks a few beers on weekends.  He does not use tobacco or injection drugs.
The patient's vital signs are within normal parameters, and physical examination is significant only for diffuse tattoos over the upper extremities.  Serum chemistry is normal, and viral hepatitis screening is positive for hepatitis C IgG antibody alone.  HIV testing is negative.  After careful discussion about safe sex practices, which of the following is the most appropriate next step regarding PrEP use in this patient?

Quizplus · Accepted Answer

Pre-exposure prophylaxis (PrEP) can reduce the risk of HIV acquisition by >90% and is generally offered to those at substantial risk for new HIV infection due to: Sexual behaviors - HIV-positive partner with detectable viral load; men who have sex with men and individuals from high prevalence areas (eg, sub-Saharan Africa) with recent bacterial sexually transmitted infection, sex exchange for money, inconsistent condom use, or high number of partnersInjection drug use - HIV-positive injecting partner; sharing of injecting equipment Sexual behaviors - HIV-positive partner with detectable viral load; men who have sex with men and individuals from high prevalence areas (eg, sub-Saharan Africa) with recent bacterial sexually transmitted infection, sex exchange for money, inconsistent condom use, or high number of partners Injection drug use - HIV-positive injecting partner; sharing of injecting equipment Treatment includes the use of once-daily 2-drug antiretroviral therapy with tenofovir plus emtricitabine. Two-drug therapy would incompletely treat active HIV infections, which can lead to drug resistance; therefore, to qualify for PrEP, patients must have negative fourth-generation HIV testing and no manifestations of acute HIV. Normal renal function and documented hepatitis B infection/vaccination status is also required. As hepatitis B can also be treated with tenofovir, patients with chronic hepatitis B infections can sometimes undergo combined hepatitis B and PrEP treatment. Patients on PrEP require follow-up every 3 months for HIV testing, risk-reduction counseling, and medication adherence/side-effect assessment. Regular creatinine levels and screening for bacterial sexually transmitted infections is also recommended. (Choice A) Direct-acting antiviral treatment for chronic hepatitis C does not usually interfere with the administration of PrEP. (Choices B and C) Multiple sexual partners and injection drug use are indications, not contraindications, for the use of PrEP. (Choice E) Three-drug antiretroviral therapy is required to treat an active HIV infection but is not used for PrEP. Educational objective: Pre-exposure prophylaxis (PrEP) with a once-daily 2-drug antiretroviral regimen (tenofovir plus emtricitabine) can reduce the risk of acquiring HIV by >90%. PrEP is generally offered to those at substantial risk of new HIV infection due to sexual behaviors (eg, HIV-positive partner, inconsistent/no condom use) or injection drug use. To qualify, patients must have negative fourth-generation HIV testing, no manifestations of acute HIV, normal renal function, and documented hepatitis B infection/vaccination status. __________

A 27-Year-Old Man Comes to the Office to Discuss HIV