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Karris MY, Lau M, Blumenthal J. Preventive and Sexual Health in LGBTQ+ Older Adults. Clin Geriatr Med 2024; 40:223-237. [PMID: 38521594 DOI: 10.1016/j.cger.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Abstract
Sexual health is an important but often overlooked health concern of LGBTQ + older adults. Multiple factors influence sexual health including intersecting identities; adverse life events; coping mechanisms; and psychological, social, and physical health domains. Thus, the use of a culturally competent and comprehensive person-centered approach to sexual health is warranted. In this review, we discuss approaches to engaging LGBTQ + older adults to ensure they are able to achieve their sexual health priorities and prevent new human immunodeficiency virus infections. We also discuss doxycycline postexposure prophylaxis to prevent other sexually transmitted infections and the impact of chemsex.
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Affiliation(s)
- Maile Young Karris
- Department of Medicine, University of California San Diego, San Diego, CA, USA.
| | - Megan Lau
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Jill Blumenthal
- Department of Medicine, University of California San Diego, San Diego, CA, USA
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Van Praet JT, Henrard S, Kenyon C, Libois A, Meuwissen A, Sauvage AS, Vincent A, Vanhamel J, Scheerder G. Belgian 2024 guidance on the use of pre-exposure prophylaxis. Acta Clin Belg 2024; 79:121-129. [PMID: 38775082 DOI: 10.1080/17843286.2024.2356337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/12/2024] [Indexed: 05/24/2024]
Abstract
OBJECTIVES We aimed to develop a guidance on the use of pre-exposure prophylaxis (PrEP) for HIV tailored to the Belgian context. METHODS Different aspects of PrEP care were judged by an expert group of nine Belgian clinicians, seeking consensus for areas of controversies. RESULTS PrEP should be considered in HIV negative patients at high risk of acquiring HIV. Currently, only oral tenofovir/emtricitabine is available in Belgium for PrEP, which can be used daily, or also event-driven in cisgender men and trans women who are not taking exogenous estradiol-based hormones. Personal counselling directed at medication adherence and sexual health should have a central role in PrEP care. At the initial assessment clinicians should give attention to symptoms of an acute HIV infection, the patients' immunization status and renal function. A regular follow-up must be set up to diagnose HIV seroconversion, treat sexually transmitted infections, and manage side effects of PrEP. CONCLUSION The Belgian guidance on the use of PrEP provides a point of reference for standard PrEP care in Belgium and will be periodically updated.
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Affiliation(s)
- Jens T Van Praet
- Department of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge AV, Brugge, Belgium
| | - Sophie Henrard
- Department of Internal Medicine and Immunodeficiency, Clinique Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Chris Kenyon
- Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | - Agnès Libois
- Department of Infectious Diseases, Saint Pierre University Hospital, Brussels, Belgium
| | - Annelies Meuwissen
- Department of Internal Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Anne-Sophie Sauvage
- Department of Infectious Diseases, Liège University Hospital, Liège, Belgium
| | - Anne Vincent
- Department of Internal Medicine, Cliniques Universitaires, Saint-Luc, Brussels, Belgium
| | - Jef Vanhamel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Gert Scheerder
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Heron JE, McManus H, Vickers T, Ryan K, Wright E, Carter A, Stoove M, Asselin J, Grulich A, Donovan B, Guy R, Varma R, Chen M, Ryder N, Lewis DA, Templeton DJ, O’Connor CC, Gracey DM. Renal impairment associated with tenofovir disoproxil fumarate for antiretroviral therapy and HIV pre-exposure prophylaxis: An observational cohort study. PLoS One 2023; 18:e0280339. [PMID: 36827395 PMCID: PMC9955644 DOI: 10.1371/journal.pone.0280339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 12/27/2022] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Tenofovir disoproxil fumarate (TDF) is associated with adverse renal outcomes when prescribed for HIV infection. There are few data concerning real-world renal outcomes amongst patients prescribed TDF for pre-exposure prophylaxis (PrEP). METHODS AND FINDINGS Data were extracted from 52 sexual health clinics across Australia from 2009-2019. All patients prescribed TDF-containing antiretroviral therapy and PrEP were included. Rates of renal impairment (a fall in eGFR to <60 ml/min/1·73m2) were calculated for people living with HIV (PLWHIV) prescribed TDF and HIV negative PrEP-users. Risk factors were assessed using Cox-proportional hazards models. Sensitivity analysis of risk using 1:1 propensity-score matching to adjust for potential imbalance in HIV and PrEP cohorts was conducted. 5,973 patients on PrEP and 1,973 PLWHIV were included. There were 39 (0.7%) instances of renal impairment in the PrEP group and 81 (4.1%) in the PLWHIV cohort (hazard ratio [HR]:0.35 95% confidence interval [CI]: 0.22-0.56). Rates of renal impairment were 4.01/1000 person-years (95%CI:2.93-5.48) in the PrEP cohort and 16.18/1000 person-years (95%CI:13.01-20.11) in the PLWHIV cohort (p<0.001). Predictors of renal impairment were: older age (40-49 years (HR:5.09 95%CI: 2.12-12.17) and 50-82 years (HR:13.69 95%CI: 5.92-31.67) (compared with 30-39 years) and baseline eGFR<90ml/min (HR:61.19 95%CI: 19.27-194.30). After adjusting for age and baseline eGFR the rate of renal impairment remained lower in the PrEP cohort (aHR:0.62 95%CI: 0.40-0.94, p = 0.023). In propensity-matched analysis using 1,622 patients per cohort the risk of renal impairment remained higher in the PLWHIV cohort (log-rank p = 0.001). CONCLUSION Patients prescribed TDF-based PrEP had lower rates of renal impairment than patients prescribed TDF for HIV infection. In propensity analysis, after matching for some risk factors, rates of renal impairment remained higher amongst patients with HIV.
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Affiliation(s)
- Jack E. Heron
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Department of Medicine, Albury Wodonga Health, Wodonga, Victoria, Australia
- * E-mail:
| | - Hamish McManus
- The Kirby Institute, University of New South Wales, Kensington, New South Wales, Australia
| | - Tobias Vickers
- The Kirby Institute, University of New South Wales, Kensington, New South Wales, Australia
| | - Kathleen Ryan
- Department of Infectious Disease, Alfred Health, Melbourne, Victoria, Australia
- Burnet Institute, Melbourne, Victoria, Australia
| | - Edwina Wright
- Department of Infectious Disease, Alfred Health, Melbourne, Victoria, Australia
- Burnet Institute, Melbourne, Victoria, Australia
- Peter Doherty Institute, Melbourne, Victoria, Australia
| | - Allison Carter
- The Kirby Institute, University of New South Wales, Kensington, New South Wales, Australia
| | - Mark Stoove
- Burnet Institute, Melbourne, Victoria, Australia
| | | | - Andrew Grulich
- The Kirby Institute, University of New South Wales, Kensington, New South Wales, Australia
| | - Basil Donovan
- The Kirby Institute, University of New South Wales, Kensington, New South Wales, Australia
| | - Rebecca Guy
- The Kirby Institute, University of New South Wales, Kensington, New South Wales, Australia
| | - Rick Varma
- The Kirby Institute, University of New South Wales, Kensington, New South Wales, Australia
- Sydney Sexual Health Centre, Sydney Hospital, Sydney, New South Wales, Australia
| | - Marcus Chen
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Nathan Ryder
- The Kirby Institute, University of New South Wales, Kensington, New South Wales, Australia
- Hunter New England Clinic, Tamworth, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - David A. Lewis
- Western Sydney Sexual Health Centre, Western Sydney Local Health District, Parramatta, New South Wales, Australia
- Faculty of Medicine and Health, Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Westmead, New South Wales, Australia
| | - David J. Templeton
- Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
- Department of Sexual Health Medicine and Sexual Assault Medical Service, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Catherine C. O’Connor
- The Kirby Institute, University of New South Wales, Kensington, New South Wales, Australia
| | - David M. Gracey
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
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Candler E, Naeem Khan M, Gratrix J, Plitt S, Stadnyk M, Smyczek P, Anderson N, Carter J, Sayers S, Smith D, Ugarte-Torres A, Shukalek C, Singh AE. Retrospective audit of a convenience cohort of individuals on HIV pre-exposure prophylaxis in Alberta, Canada. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2022; 7:350-363. [PMID: 37397818 PMCID: PMC10312220 DOI: 10.3138/jammi-2022-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 06/24/2022] [Accepted: 06/26/2022] [Indexed: 07/04/2023]
Abstract
BACKGROUND We undertook an audit of a province-wide HIV pre-exposure prophylaxis (PrEP) program in Alberta (Canada). METHODS A retrospective record review of individuals accessing PrEP in Alberta included demographics, PrEP indication(s), and reported non-prescription drug and alcohol use from March 2016 to June 2019. Hepatitis A, B, C, HIV and syphilis serology, serum creatinine, and nucleic acid amplification tests testing for chlamydia and gonorrhea were collected. Descriptive statistics, incidence, and prevalence were calculated. RESULTS A total of 511 participants were seen at STI, sexual, and reproductive health clinics and private family practitioner (FP) offices; 98.4% (503) were men, median age was 34 years (IQR 28-43 years), and 89.8% (459) were gay or bisexual men who have sex with men. Non-prescription drug use was reported by 39.3% (201) and alcohol use by 55.4% (283). 94.3% (482) reported condomless anal sex in the past 6 months. Testing rates were high (>95%) for all tests except for chlamydia and gonorrhea at the first follow-up visit 89.6%; (3-4 months). There was one HIV seroconversion. The incidence of new bacterial STIs was high: chlamydia 17 cases per 100 person-years (95% CI 13.5% to 21.4%), gonorrhea 11.14 cases per 100 person-years (95% CI 8.3% to 15.0%), and syphilis 1.94 cases per 100 person-years (95% CI 0.73% to 5.12%). CONCLUSIONS Following implementation of a provincial program for PrEP in Alberta, PrEP initiation and continuation was feasible in a range of settings and by both specialists and FPs.
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Affiliation(s)
- Ethan Candler
- STI Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Muhammad Naeem Khan
- Health Protection Communicable Disease Control, Population, Public and Indigenous Health, Alberta Health Services, Edmonton, Alberta, Canada
| | - Jennifer Gratrix
- STI Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Sabrina Plitt
- Centre for Communicable Disease and Infection Control, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Maria Stadnyk
- STI Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Petra Smyczek
- STI Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Natalie Anderson
- Sexual and Reproductive Health Clinics, Calgary, Alberta, Canada
| | - Julia Carter
- Sexual and Reproductive Health Clinics, Calgary, Alberta, Canada
| | | | - Donna Smith
- Red Deer Sexual Health Clinic, Red Deer, Alberta, Canada
| | - Alejandra Ugarte-Torres
- Department of Medicine, Division of Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Caley Shukalek
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Nhean S, Tseng A, Sheehan NL, Bogoch II. Use and safety of appearance and performance enhancing supplements in gay, bisexual, and other men who have sex with men receiving daily tenofovir disoproxil fumarate/emtricitabine as HIV pre-exposure prophylaxis. AIDS Care 2022; 35:488-494. [PMID: 36102034 DOI: 10.1080/09540121.2022.2121958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Appearance- and performance-enhancing supplements (APES) may be associated with liver and renal toxicity, but use is often under-reported. This study describes the use and safety of APES among gay, bisexual, and other men-who-have-sex with men (gbMSM) attending an urban HIV pre-exposure prophylaxis (PrEP) clinic. A cross-sectional study was conducted between February 2018 to September 2018 to assess APES usage in gbMSM taking daily tenofovir disoproxil fumarate/emtricitabine for PrEP. Renal and liver function were assessed from electronic medical records. Among 50 participants (98% male, median 32 years, 52% White, on PrEP for a median 4.4 years), 72% reported lifetime APES use, with 52% currently using APES (median 1.5 products/person) and 28% never used APES. The most common products included whey protein, creatine supplements and anabolic steroids. The primary reason for APES use was to increase muscle mass. Three (12%) current APES users had elevated serum creatinine (stage 1) versus zero (0%) in the non-APES group. Two (8%) current APES users experienced grade 3-4 ALT/AST elevations versus zero (0%) in the non-APES group. APES usage among gbMSM taking PrEP was high and may be associated with liver/renal lab abnormalities. Increased awareness of APES use and potential toxicity is encouraged to enhance safety.
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Affiliation(s)
- Salin Nhean
- Doctors Community Medical Center, Lanham, MD, USA.,Correct Rx Pharmacy Services, Hanover, MD, USA
| | - Alice Tseng
- Immunodeficiency Clinic, University Health Network, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto Canada
| | - Nancy L Sheehan
- McGill University Health Center, Montréal, Canada.,Université de Montréal, Montréal, Canada
| | - Isaac I Bogoch
- Immunodeficiency Clinic, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
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Safety of oral tenofovir disoproxil - emtricitabine for HIV preexposure prophylaxis in adults. Curr Opin HIV AIDS 2022; 17:199-204. [PMID: 35762374 DOI: 10.1097/coh.0000000000000747] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review focuses on the safety of oral tenofovir disoproxil and emtricitabine (FTC) combination for HIV preexposure prophylaxis (PrEP) in adults. RECENT FINDINGS Gastrointestinal adverse events are common after treatment initiation but usually resolve within weeks. Although clinical trials did not report an increased risk of serious renal adverse events or tubulopathy, meta-analyses suggest that tenofovir disoproxil -FTC is associated with a slight but non-clinically relevant decline in estimated glomerular filtration rate (eGFR). A decline to less than 60 mL/min remains a rare event, which mainly occurs in users with an age >50 years or a baseline creatinine clearance < 90 mL/min. Similarly, a slight reduction in bone mineral density (BMD) was observed in clinical trials, but it did not result in an increased risk of bone fracture. BMD reduction and eGFR decline tend to resolve after treatment discontinuation. No drug interaction with contraception has been reported in women and no safety signal emerged in pregnant and breastfeeding women. SUMMARY Oral tenofovir disoproxil-FTC for HIV PrEP appears safe and well tolerated for most individuals. This supports demedicalization strategies aiming at increasing the number of PrEP users.
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Drak D, Lin J, Gowers A, Gracey DM. Fanconi syndrome in a patient receiving pre-exposure prophylaxis for HIV infection: case report. Sex Health 2022; 19:224-227. [PMID: 35614021 DOI: 10.1071/sh21185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 05/04/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Tenofovir disoproxil is efficacious in the preventing HIV infection as part of a pre-exposure prophylaxis (PrEP) regimen. Although its use has been associated with impaired renal function, instances of Fanconi syndrome are extremely rare. This may change with increased uptake of PrEP. METHODS A 55-year-old male patient (he/him/his) was commenced on PrEP with a baseline estimated glomerular filtration rate (eGFR) of approximately 60mL/min/1.73m2. RESULTS Within 6months, he developed new and worsening proteinuria, glycosuria and aminoaciduria despite no apparent change in eGFR. PrEP was discontinued and his urinary abnormalities rapidly resolved. The patient remains off PrEP. CONCLUSIONS Fanconi syndrome is a rare, but known complication of tenofovir disoproxil. This is the first report related to PrEP in Australia. While tenofovir associated nephrotoxicity in patients taking PrEP is uncommon, the patient's age and pre-existing renal impairment placed him at substantially higher risk. At-risk patients need more frequent monitoring of their eGFR and proteinuria. Urinary protein to creatinine ratio is the preferred to dipstick testing for proteinuria and the latter does not readily detect the low molecular wight proteinuria characteristic of tenofovir toxicity. Early recognition of these patients is essential, as prompt cessation of PrEP can often reverse renal abnormalities.
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Affiliation(s)
- Douglas Drak
- Royal North Shore Hospital, St Leonards, NSW, Australia; and Faculty of Medicine, Central Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Jasper Lin
- Renal Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Andrew Gowers
- Holdsworth House Medical Practice, College Street, Sydney, NSW, Australia
| | - David M Gracey
- Faculty of Medicine, Central Clinical School, University of Sydney, Sydney, NSW, Australia; and Renal Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; and Holdsworth House Medical Practice, College Street, Sydney, NSW, Australia
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Schaefer R, Amparo da Costa Leite PH, Silva R, Abdool Karim Q, Akolo C, Cáceres CF, Dourado I, Green K, Hettema A, Hoornenborg E, Jana S, Kerschberger B, Mahler H, Matse S, McManus H, Molina JM, Reza-Paul S, Azwa I, Shahmanesh M, Taylor D, Vega-Ramirez H, Veloso VG, Baggaley R, Dalal S. Kidney function in tenofovir disoproxil fumarate-based oral pre-exposure prophylaxis users: a systematic review and meta-analysis of published literature and a multi-country meta-analysis of individual participant data. Lancet HIV 2022; 9:e242-e253. [PMID: 35271825 PMCID: PMC8964504 DOI: 10.1016/s2352-3018(22)00004-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Previous WHO guidance on tenofovir disoproxil fumarate-based oral pre-exposure prophylaxis (PrEP) suggests measuring creatinine levels at PrEP initiation and regularly afterwards, which might represent barriers to PrEP implementation and uptake. We aimed to systematically review published literature on kidney toxicity among tenofovir disoproxil fumarate-based oral PrEP users and conducted an individual participant data meta-analysis (IPDMA) on kidney function among PrEP users in a global implementation project dataset. METHODS In this systematic review and meta-analysis we searched PubMed up to June 30, 2021, for randomised controlled trials (RCTs) or cohort studies that reported on graded kidney-related adverse events among oral PrEP users (tenofovir disoproxil fumarate-based PrEP alone or in combination with emtricitabine or lamivudine). We extracted summary data and conducted meta-analyses with random-effects models to estimate relative risks of grade 1 and higher and grade 2 and higher kidney-related adverse events, measured by elevated serum creatinine or decline in estimated creatinine clearance or estimated glomerular filtration rate. The IPDMA included (largely unpublished) individual participant data from 17 PrEP implementation projects and two RCTs. Estimated baseline creatinine clearance and creatinine clearance change after initiation were described by age, gender, and comorbidities. We used random-effects regressions to estimate the risk in decline of creatinine clearance to less than 60 mL/min. FINDINGS We identified 62 unique records and included 17 articles reporting on 11 RCTs with 13 523 participants in meta-analyses. PrEP use was associated with increased risk of grade 1 and higher kidney adverse events (pooled odds ratio [OR] 1·49, 95% CI 1·22-1·81; I2=25%) and grade 2 and higher events (OR 1·75, 0·68-4·49; I2=0%), although the grade 2 and higher association was not statistically significant and events were rare (13 out of 6764 in the intervention group vs six out of 6782 in the control group). The IPDMA included 18 676 individuals from 15 countries (1453 [7·8%] from RCTs) and 79 (0·42%) had a baseline estimated creatinine clearance of less than 60 mL/min (increasing proportions with increasing age). Longitudinal analyses included 14 368 PrEP users and 349 (2·43%) individuals had a decline to less than 60 mL/min creatinine clearance, with higher risks associated with increasing age and baseline creatinine clearance of 60·00-89·99 mL/min (adjusted hazard ratio [aHR] 8·49, 95% CI 6·44-11·20) and less than 60 mL/min (aHR 20·83, 12·83-33·82). INTERPRETATION RCTs suggest that risks of kidney-related adverse events among tenofovir disoproxil fumarate-based oral PrEP users are increased but generally mild and small. Our global PrEP user analysis found varying risks by age and baseline creatinine clearance. Kidney function screening and monitoring might focus on older individuals, those with baseline creatinine clearance of less than 90 mL/min, and those with kidney-related comorbidities. Less frequent or optional screening among younger individuals without kidney-related comorbidities may reduce barriers to PrEP implementation and use. FUNDING Unitaid, Bill & Melinda Gates Foundation, WHO.
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Affiliation(s)
- Robin Schaefer
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland.
| | | | - Ronaldo Silva
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Quarraisha Abdool Karim
- CAPRISA, Nelson R Mandela School of Medicine; University of KwaZulu-Natal, Durban, South Africa
| | | | - Carlos F Cáceres
- Centro de Investigación Interdisciplinaria en Sexualidad, SIDA y Sociedad, Universidad Cayetano Heredia, Lima, Peru
| | - Inês Dourado
- Collective Health Institute, Federal University of Bahia, Brazil
| | | | | | - Elske Hoornenborg
- Center for Sexual Health, Department of Infectious Diseases, Public Health Service Amsterdam, Amsterdam, Netherlands
| | | | | | | | | | - Hamish McManus
- The Kirby Institute, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Jean-Michel Molina
- Department of Infectious Diseases, St-Louis and Lariboisière Hospitals, University of Paris, INSERM U944, Paris, France
| | - Sushena Reza-Paul
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada; Ashodaya Samithi, Mysuru, India
| | - Iskandar Azwa
- Infectious Diseases Unit, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Institute for Global Health, University College London, London, UK
| | | | - Hamid Vega-Ramirez
- National Institute of Psychiatry Ramon de la Fuente Muñiz, Mexico City, Mexico
| | - Valdiléa G Veloso
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Rachel Baggaley
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - Shona Dalal
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
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Petruccelli KCS, Baía-da-Silva DC, Val F, Valões MS, Cubas-Vega N, Silva-Neto AV, Sampaio V, Alencar A, Pecoits-Filho R, Moreira RC, Cardoso SW, Moreira RI, Leite IC, Madruga JV, Kallas EG, Alencastro PR, Hoagland B, Grinsztejn B, Santos VGV, Lacerda MVG. Kidney function and daily emtricitabine/tenofovir disoproxil fumarate pre-exposure prophylaxis against HIV: results from the real-life multicentric demonstrative project PrEP Brazil. AIDS Res Ther 2022; 19:12. [PMID: 35209929 PMCID: PMC8867642 DOI: 10.1186/s12981-022-00437-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 02/07/2022] [Indexed: 12/02/2022] Open
Abstract
Background Pre-Exposure Prophylaxis (PrEP) has demonstrated efficacy in the reduction of sexually transmitted HIV infections. The prolonged use of tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) co-formulation (TDF/FTC), however, may result in augmented risk of renal toxicity. We aimed to evaluate changes in the estimated Glomerular Filtration Rate (eGFR) in a real-world population setting of participants enrolled in PrEP Brazil, a 48-week prospective, open-label, demonstration study to assess the feasibility of daily oral TDF/FTC used by men who have sex with men and transgender women at high-risk of HIV infection, all over 18 years old. Methods Kidney function was assessed by serial measurement of serum creatinine and eGFR with the Modification of Diet in Renal Disease Study (MDRD) formula on weeks 4, 12, 24, 36 and 48. Adherence to PrEP was assessed by dosing TDF concentration in dried blood spots at weeks 4 and 48, measured by liquid chromatography-mass spectrometry or mass spectrometry. Results Of 392 participants completing the 48-week follow-up protocol with TDF blood detectable levels and eGFR measures, 43.1% were young adults, of Caucasian ethnic background (57.9%), with BMI below 30 kg/m2, without arterial hypertension. At screening, median eGFR was 93.0 mL/min/1.73 m2. At week 4 follow-up, 90 (23% of the study population) participants presented reductions in eGFR greater than 10 mL/min/1.73 m2 as compared to baseline eGFR, some as large as 59 mL/min/1.73 m2, but with no clinical outcomes (adverse events and renal adverse events) severe enough to demand TDF/FTC discontinuation. A negative relationship was observed between TDF blood levels and eGFR at weeks 4 (r = − 0.005; p < 0.01) and 48 (r = − 0.006; p < 0.01). Conclusions These results suggest that the renal function profile in individuals on TDF/FTC may be assessed on week 4 and then only annually, allowing a more flexible medical follow-up in primary care centers. Supplementary Information The online version contains supplementary material available at 10.1186/s12981-022-00437-4.
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Affiliation(s)
| | - Djane Clarys Baía-da-Silva
- Universidade do Estado do Amazonas, Manaus, Brazil.,Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Av Pedro Teixeira, 25, Manaus, Amazonas, 69040-000, Brazil.,Instituto Leônidas and Maria Deane, Fiocruz, Manaus, Brazil
| | - Fernando Val
- Universidade do Estado do Amazonas, Manaus, Brazil.,Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Av Pedro Teixeira, 25, Manaus, Amazonas, 69040-000, Brazil
| | - Monica Santos Valões
- Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Av Pedro Teixeira, 25, Manaus, Amazonas, 69040-000, Brazil
| | | | - Alexandre Vilhena Silva-Neto
- Universidade do Estado do Amazonas, Manaus, Brazil.,Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Av Pedro Teixeira, 25, Manaus, Amazonas, 69040-000, Brazil
| | - Vanderson Sampaio
- Universidade do Estado do Amazonas, Manaus, Brazil.,Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Av Pedro Teixeira, 25, Manaus, Amazonas, 69040-000, Brazil.,Fundação de Vigilância em Saúde do Amazonas, Manaus, Brazil
| | - Aline Alencar
- Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Av Pedro Teixeira, 25, Manaus, Amazonas, 69040-000, Brazil
| | | | | | - Sandra Wagner Cardoso
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fiocruz, Rio de Janeiro, Brazil
| | - Ronaldo I Moreira
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fiocruz, Rio de Janeiro, Brazil
| | - Iuri Costa Leite
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fiocruz, Rio de Janeiro, Brazil
| | | | - Esper G Kallas
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Brenda Hoagland
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fiocruz, Rio de Janeiro, Brazil
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fiocruz, Rio de Janeiro, Brazil
| | | | - Marcus Vinícius Guimarães Lacerda
- Universidade do Estado do Amazonas, Manaus, Brazil. .,Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Av Pedro Teixeira, 25, Manaus, Amazonas, 69040-000, Brazil. .,Instituto Leônidas and Maria Deane, Fiocruz, Manaus, Brazil.
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10
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Mugwanya KK, Matemo D, Scoville CW, Beima-Sofie KM, Meisner A, Onyango D, Mugambi M, Feutz E, Grabow C, Barnabas R, Weiner B, Baeten JM, Kinuthia J. Integrating PrEP delivery in public health family planning clinics: a protocol for a pragmatic stepped wedge cluster randomized trial in Kenya. Implement Sci Commun 2021; 2:135. [PMID: 34895357 PMCID: PMC8665600 DOI: 10.1186/s43058-021-00228-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/15/2021] [Indexed: 12/14/2022] Open
Abstract
Background Adolescent girls and young women account for a disproportionate fraction of new HIV infections in Africa and are a priority population for HIV prevention, including provision of pre-exposure prophylaxis (PrEP). Anchoring PrEP delivery to care settings like family planning (FP) services that women already access routinely may offer an efficient platform to reach HIV at-risk women. However, context-specific implementation science evaluation is needed. Methods The Family Planning Plus Project is a prospective, pragmatic implementation evaluation, designed as a stepped wedge, cluster randomized trial, at 12 clinics in Kenya. In collaboration with the Kenya Ministry of Health and Kisumu County Department of Health, we will introduce integration of HIV risk screening and PrEP delivery in public health FP clinics. The core multifaceted implementation strategies to integrate PrEP in FP clinics will include: (1) PrEP delivery by existing FP clinic staff, (2) health provider training, (3) PrEP technical assistance to coach and mentor providers, (4) joint supervision with Kisumu County health officials, and (5) stakeholder engagement. All core components of PrEP delivery—including screening for HIV risk, HIV testing, dispensing, adherence and risk reduction counseling, assessment of side effects, and provision of refills, or safety assessment—will be conducted by existing FP clinic staff as part of a standard care service package. The goal is to catalyze sustainable scale-up within existing infrastructures beyond the project. We will rigorously evaluate implementation outcomes and impact, using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, and we will use Organizational Readiness for Implementing Change (ORIC) and the Consolidated Framework for Implementation Science Research (CFIR) to assess readiness to implement and contextual enablers and barriers of implementation, including how clinics innovate efficient delivery systems. Discussion Anchoring PrEP delivery to existing FP systems and staffing has tremendous potential to address barriers that women face in accessing HIV prevention and PrEP care, including lack of time, cost, and stigma of visiting a facility solely for HIV prevention. The FP Plus Project will initiate preparation for full-scale and sustainable model of integration of comprehensive HIV prevention services, including PrEP implementation, in public health FP clinics in low-income settings. Trial registration Registered with ClinicalTrials.gov on December 14, 2020: NCT04666792
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Affiliation(s)
- Kenneth K Mugwanya
- Departments of Global Health and Epidemiology, University of Washington, 325 Ninth Avenue, #HMC 359927, Seattle, WA, 98104, USA.
| | - Daniel Matemo
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | | | | | - Allison Meisner
- Department of Global Health, University of Washington, Seattle, USA.,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, USA
| | | | - Mary Mugambi
- National AIDS and STI Control Program Ministry of Health, Nairobi, Kenya
| | - Erika Feutz
- Department of Global Health, University of Washington, Seattle, USA
| | - Cole Grabow
- Department of Global Health, University of Washington, Seattle, USA
| | - Ruanne Barnabas
- Departments of Global Health and Medicine, University of Washington, Seattle, USA
| | - Bryan Weiner
- Department of Global Health, University of Washington, Seattle, USA
| | - Jared M Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, USA.,Present affiliation: Gilead Sciences, Foster City, USA
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11
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Lucas GM, Winslow DL. New onset kidney impairment in a large pre-exposure prophylaxis demonstration project in New South Wales, Australia. AIDS 2021; 35:2395-2397. [PMID: 34723855 PMCID: PMC8982901 DOI: 10.1097/qad.0000000000003077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Gregory M. Lucas
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, Maryland
| | - Dean L. Winslow
- Stanford University School of Medicine, Division of Hospital Medicine and Division of Infectious Diseases and Geographic Medicine, Stanford, California
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12
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Drak D, Mcmanus H, Vickers T, Heron JE, Vaccher S, Zablotska I, Guy R, Bavinton B, Jin F, Grulich AE, Bloch M, O'Connor CC, Gracey DM. Renal impairment in a large-scale HIV preexposure prophylaxis implementation cohort. AIDS 2021; 35:2319-2326. [PMID: 34310371 DOI: 10.1097/qad.0000000000003035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND HIV preexposure prophylaxis (PrEP) with fixed-dose tenofovir disoproxil fumarate (TDF) and emtricitabine has been associated with low rates of renal impairment in clinical trials. Large-scale PrEP implementation may result in higher rates, as the prevalence of associated risk factors may be higher than in trial populations. METHODS A posthoc analysis of EPIC-NSW, a large Australian multicentre PrEP implementation trial for patients at high risk of HIV infection. Participants were eligible for inclusion if they commenced PrEP between 1 March 2016 and 30 April 2018, and had renal function assessed at baseline and at least once more before the censor date. The primary outcome was new-onset renal impairment, defined as an estimated glomerular filtration rate (eGFR) <60 ml/min per 1.73 m2. RESULTS A total of 6808 participants were eligible for inclusion. Almost all were male (99%), with a median age of 35 years [interquartile range (IQR): 28-44]. Approximately one-quarter (26%) had a baseline eGFR <90 ml/min per 1.73 m2. Over a median follow-up period of 1.2 years (IQR: 0.6-1.7), the rate of renal impairment was 5.8 episodes per 1000 person-years [95% confidence interval (CI): 4.0-7.8]. In multivariable Cox regression, there was a higher risk of renal impairment in participants aged ≥50 years [hazard ratio (HR) 14.7, 95% CI: 5.0-43.3, P < 0.001] and those with an eGFR <90 ml/min per 1.73 m2 (HR 28.9, 95% CI: 6.9-121.9) at baseline. CONCLUSION In a large-scale implementation study, TDF-containing PrEP was associated with a low risk of renal impairment overall, whereas older patients and those with preexisting renal dysfunction were at substantially increased risk.
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Affiliation(s)
- Douglas Drak
- Central Clinical School, University of Sydney, Camperdown
- Wagga Wagga Base Hospital, Wagga Wagga
| | | | | | - Jack E Heron
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown
| | | | - Iryna Zablotska
- Westmead Clinical School, Faculty of Medicine and Health
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Westmead
- Western Sydney Sexual Health Centre, Western Sydney Local Health District, Parramatta
| | | | | | | | | | - Mark Bloch
- Holdsworth House Medical Practice, Darlinghurst, NSW, Australia
| | | | - David M Gracey
- Central Clinical School, University of Sydney, Camperdown
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown
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13
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Stalter RM, Pintye J, Mugwanya KK. Safety review of tenofovir disoproxil fumarate/emtricitabine pre-exposure prophylaxis for pregnant women at risk of HIV infection. Expert Opin Drug Saf 2021; 20:1367-1373. [PMID: 33998936 PMCID: PMC9010110 DOI: 10.1080/14740338.2021.1931680] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/14/2021] [Indexed: 02/07/2023]
Abstract
Introduction: Pregnancy is a period of elevated HIV risk in high-burden settings, motivating the need for prevention tools that are both safe for use and effective during pregnancy. Oral pre-exposure prophylaxis (PrEP) containing tenofovir disoproxil fumarate (TDF) is recommended by the World Health Organization, including for pregnant and postpartum women at substantial risk of HIV infection. Although TDF use during pregnancy appears generally safe, data on PrEP use during pregnancy remain limited.Areas covered: We provide an overview of the clinical pharmacology and efficacy of daily TDF-based PrEP and summarize current evidence on the safety of PrEP use by pregnant HIV-uninfected women. We synthesize relevant studies assessing pregnancy outcomes among pregnant women who are living with HIV (WLHIV) and using TDF-based therapy. Finally, we make comparison to the safety profiles of other emerging HIV prevention options.Expert opinion: The current evidence indicates that TDF/FTC PrEP use is not associated with increased risk of adverse pregnancy and early infant growth outcomes. While safety data are generally reassuring, there is need for continued accrual of data on growth and pregnancy outcomes in PrEP research, implementation projects, and controlled pharmacokinetic studies to support current evidence and to understand concentration-efficacy relationship in pregnant women.
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Affiliation(s)
- Randy M. Stalter
- Epidemiology Department, University of Washington, Seattle, WA, USA
| | - Jillian Pintye
- School of Nursing, University of Washington, Seattle, WA, USA
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14
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Mugwanya KK, Kinuthia J. Integrating Pre-Exposure Prophylaxis Delivery in Public Health Family Planning Clinics: Lessons Learned From a Programmatic Implementation Project in Kenya. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3:683415. [PMID: 36304007 PMCID: PMC9580668 DOI: 10.3389/frph.2021.683415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/23/2021] [Indexed: 11/25/2022] Open
Abstract
Sexually active African women are a priority population for HIV prevention due to the disproportionately high frequency of new HIV infections. Family planning (FP) clinics offer an already trusted platform that can be used to reach women for HIV prevention services, including pre-exposure prophylaxis (PrEP). In the recent PrEP Implementation in Young Women and Adolescent (PrIYA program), we piloted PrEP implementation in FP clinics in Kisumu, Kenya, and demonstrated that it was possible to integrate PrEP provision in FP systems with a program-dedicated staff. In this perspective, we describe experiences and strategies employed to introduce PrEP implementation in FP clinics and lessons learned. We identified the following lessons for PrEP introduction in FP clinics in Kenya: (1) possible to integrate and generate high enthusiasm for PrEP delivery in FP clinics but persistence on PrEP is a challenge, (2) involvement of national and regional stakeholders is critical for buy-in, contextualization, and sustainability, (3) delivery models that do not integrate fully with existing staff and systems are less sustainable, (4) creatinine testing at PrEP initiation may not be necessary, (5) fully integrated HIV and FP data systems need to be developed, and (6) incorporating implementation science evaluation is important to understand and document effective implementation strategies. In summary, integration of HIV prevention and FP services provides an opportunity to promote one-stop women-centered care efficiently. However, a broader focus on delivery models that utilize existing staff and novel strategies to help women identify their own risk for HIV are needed to ensure greater success and sustainability.
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Affiliation(s)
- Kenneth K. Mugwanya
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- *Correspondence: Kenneth K. Mugwanya
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, WA, United States
- Kenyatta National Referral Hospital, Nairobi, Kenya
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15
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Ng YC, Mayeux JJ. Initiating pre-exposure prophylaxis: What primary care providers should know. Nurse Pract 2021; 46:17-22. [PMID: 34397767 DOI: 10.1097/01.npr.0000757076.21006.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Pre-exposure prophylaxis (PrEP) is an HIV preventive service and treatment that is continuing to evolve. With the availability of in-house lab screenings and simplified testing protocols, primary care providers are in a unique position to initiate and provide the added layer of HIV protection for their patients.
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16
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Update on HIV prevention and preexposure prophylaxis. JAAPA 2020; 33:12-17. [PMID: 32384293 DOI: 10.1097/01.jaa.0000662360.74992.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HIV preexposure prophylaxis (PrEP) is an opportunity for clinicians to curb the 40,000 HIV infections occurring annually in the United States. PrEP is medication used by HIV-negative patients to reduce their risk of acquiring the virus. This article provides a baseline understanding of PrEP indications, prescribing, and monitoring, including a review of previously approved medication and an update on newly approved drugs, including emtricitabine/tenofovir alafenamide (F/TAF). Sexual and gender minorities are often underrepresented in the literature about PrEP, but clinicians should address risk focused on specific behaviors rather than population-level characteristics. As one of few professions with prescriptive authority, PAs have an obligation to understand and manage PrEP.
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17
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Rowan SE, Patel RR, Schneider JA, Smith DK. Same-day prescribing of daily oral pre-exposure prophylaxis for HIV prevention. Lancet HIV 2020; 8:e114-e120. [PMID: 33128874 DOI: 10.1016/s2352-3018(20)30256-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 07/08/2020] [Accepted: 07/28/2020] [Indexed: 01/26/2023]
Abstract
Pre-exposure prophylaxis (PrEP) is highly effective in reducing HIV transmission but remains underutilised globally. Same-day PrEP prescribing and medication provision is an emerging implementation approach. The experiences of the three same-day PrEP programmes support the feasibility of the approach. Key elements of safe and effective same-day PrEP programmes include the ability to order laboratory tests at the time of the clinical visit and the ability to contact patients when laboratory results are available. Same-day PrEP has the potential to alleviate the attrition seen in usual care between initial evaluation and receipt of a PrEP prescription. A widespread application of same-day prescribing will be needed to assess its effect on PrEP usage.
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Affiliation(s)
| | - Rupa R Patel
- Division of Infectious Diseases, Washington University in St Louis, St Louis, MO, USA.
| | | | - Dawn K Smith
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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18
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Heron JE, Rix S, Varma R, Gracey DM. Renal impairment: an unnecessary barrier to HIV prevention. Sex Health 2020; 17:299-300. [PMID: 32576363 DOI: 10.1071/sh20037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/21/2020] [Indexed: 11/23/2022]
Abstract
The use of tenofovir disoproxil fumarate (TDF) in combination with emtricitabine, prescribed for pre-exposure prophylaxis (PrEP), is highly effective at reducing incident sexually transmissible HIV infection among those at risk. TDF is associated with proteinuria, Fanconi syndrome and chronic kidney disease, and is not recommended for use in patients with an estimated creatinine clearance <60 mL min-1. There are currently no Pharmaceutical Benefits Scheme (PBS)-funded PrEP options for patients at risk of HIV infection with moderate renal impairment in Australia. This report describes the case of a patient who acquired HIV soon after PrEP was suspended due to moderate renal impairment. The various clinical and regulatory issues this case raises are discussed.
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Affiliation(s)
- Jack E Heron
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia; and Corresponding author.
| | - Suzanne Rix
- Sydney Sexual Health Centre, South Eastern Sydney Local Health District, Sydney, NSW 2000, Australia
| | - Rick Varma
- Sydney Sexual Health Centre, South Eastern Sydney Local Health District, Sydney, NSW 2000, Australia
| | - David M Gracey
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia; and Central Clinical School, The University of Sydney, Sydney, NSW 2006, Australia
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19
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Brady M, Rodger A, Asboe D, Cambiano V, Clutterbuck D, Desai M, Field N, Harbottle J, Jamal Z, McCormack S, Palfreeman A, Portman M, Quinn K, Tenant-Flowers M, Wilkins E, Young I. BHIVA/BASHH guidelines on the use of HIV pre-exposure prophylaxis (PrEP) 2018. HIV Med 2020; 20 Suppl 2:s2-s80. [PMID: 30869189 DOI: 10.1111/hiv.12718] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Michael Brady
- Consultant in Sexual Health and HIV, King's College Hospital, London
| | - Alison Rodger
- Reader and Honorary Consultant Infectious Diseases and HIV, University College London
| | - David Asboe
- Consultant HIV and Sexual Health, Chelsea and Westminster Hospital NHS Foundation Trust, London
| | - Valentina Cambiano
- Lecturer in Infectious Disease Modelling and Biostatistics, University College London
| | | | - Monica Desai
- Consultant Epidemiologist, Public Health England
| | - Nigel Field
- Senior Lecturer, Consultant Clinical Epidemiologist, University College London
| | | | | | - Sheena McCormack
- Professor of Clinical Epidemiology, MRC Clinical Trials Unit at University College London
| | - Adrian Palfreeman
- Consultant HIV and Sexual Health, University Hospitals of Leicester NHS Trust
| | - Mags Portman
- Consultant HIV and Sexual Health, Mortimer Market Centre, London
| | - Killian Quinn
- Consultant HIV and Sexual Health, King's College Hospital, London
| | | | - Ed Wilkins
- Consultant in Infectious Diseases, North Manchester General Hospital
| | - Ingrid Young
- Chancellor's Fellow, Usher Institute, University of Edinburgh
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20
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Clifford-Rashotte M, Fawcett N, Fowler B, Reinhart J, Tan DHS. Assessing the Potential for Nurse-Led HIV Pre- and Postexposure Prophylaxis in Ontario. Can J Nurs Res 2020; 53:145-154. [PMID: 32380845 DOI: 10.1177/0844562120924269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND AND PURPOSE HIV prevention efforts in Ontario require increased implementation of strategies including post- and pre-exposure prophylaxis. Access to these interventions could be improved by their provision through nurse-led models of care. We assessed nurses' readiness to deliver these interventions using a behavioral change framework. METHODS We distributed an online survey to nurses in every Ontario sexual health clinic, HIV clinic, and community health center between March-June 2018, to determine the level of support for nurse-led postexposure prophylaxis/pre-exposure prophylaxis; we also explored nurses' "capabilities," "opportunities," and "motivations" for providing postexposure prophylaxis/pre-exposure prophylaxis. RESULTS Overall, 72.7% of respondents supported implementation of both nurse-led postexposure prophylaxis and pre-exposure prophylaxis. More experienced nurses were less likely to support nurse-led postexposure prophylaxis and pre-exposure prophylaxis (adjusted odds ratio = 0.55 per decade nursing, 95% confidence interval (0.37, 0.82)). Nurses reported a high degree of knowledge of topics related to postexposure prophylaxis/pre-exposure prophylaxis, with the exception of creatinine interpretation. CONCLUSIONS Ontario nurses report high levels of support for nurse-led postexposure prophylaxis and pre-exposure prophylaxis and are well positioned to provide these interventions. Targeted education and implementation efforts are needed to engage these nurses in postexposure prophylaxis and pre-exposure prophylaxis delivery.
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Affiliation(s)
| | | | - Barbara Fowler
- Region of Peel Health Department, Mississauga, Ontario, Canada
| | | | - Darrell H S Tan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, St. Michael's Hospital, Toronto, Ontario, Canada.,Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
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21
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Celum C, Baeten J. PrEP for HIV Prevention: Evidence, Global Scale-up, and Emerging Options. Cell Host Microbe 2020; 27:502-506. [PMID: 32272075 DOI: 10.1016/j.chom.2020.03.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Antiretroviral pre-exposure prophylaxis (PrEP) for the prevention of HIV infection was demonstrated to be efficacious and safe earlier this decade from pivotal studies using oral emtricitabine-tenofovir disoproxil fumarate. Regulatory approval and normative guidance, now for almost 70 countries worldwide, has followed. Demonstration projects have shown high uptake and population-level HIV reductions, highlighting the need for simplifying delivery and reducing current barriers to access and persistence. A portfolio of additional, next-generation PrEP formulations, currently under testing, if effective, will offer users choice and likely increase coverage and impact.
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22
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Ascher SB, Scherzer R, Estrella MM, Shigenaga J, Spaulding KA, Glidden DV, Mehrotra ML, Defechereux P, Gandhi M, Grant RM, Shlipak MG, Jotwani V. HIV preexposure prophylaxis with tenofovir disoproxil fumarate/emtricitabine and changes in kidney function and tubular health. AIDS 2020; 34:699-706. [PMID: 31794523 PMCID: PMC7071971 DOI: 10.1097/qad.0000000000002456] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To evaluate the effects of HIV preexposure prophylaxis (PrEP) with tenofovir disoproxial fumurate (TDF)/emtricitabine (FTC) on kidney function and kidney tubular health. DESIGN The Iniciativa Profilaxis Pre-Exposicion open-label extension (iPrEx-OLE) study enrolled former PrEP trial participants to receive open-label TDF/FTC. This study included 123 iPrEx-OLE participants who demonstrated PrEP adherence. METHODS We compared estimated glomerular filtration rate calculated using serum creatinine (eGFRcr), serum cystatin C (eGFRcys), and in combination (eGFRcr-cys), and a panel of 14 urine biomarkers reflecting kidney tubular health before and 6 months after PrEP initiation. RESULTS At baseline, mean eGFRcr, eGFRcys, and eGFRcr-cys were 108.3, 107.0, and 111.1 ml/min per 1.73 m, respectively. Six months after PrEP initiation, eGFRcr declined by -4% (95% CI: -5.7 to -2.4%), eGFRcys declined by -3.3% (95% CI: -8.3 to 1.9%), and eGFRcr-cys declined by -4.1% (95% CI: -7.5 to -0.7%). From the urine biomarker panel, α1-microglobulin and β2-microglobulin increased by 22.7% (95% CI: 11.8--34.7%) and 14.1% (95% CI: -6.1 to 38.6%), whereas chitinase-3-like 1 protein and monocyte chemoattractant protein-1 decreased by -37.7% (95% CI: -53.0 to -17.3%) and -15.6% (95% CI: -31.6 to 4.2%), respectively. Ten of the 14 urine biomarkers, including albumin, had estimated changes of less than 12% with wide confidence intervals. CONCLUSION Six months of PrEP with TDF/FTC was associated with decreases in eGFRcr and eGFRcys. We also observed for the first time changes in flour of 14 urine biomarkers reflecting kidney tubular health. These findings demonstrate that PrEP has direct effects on eGFR and the proximal tubule.
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Affiliation(s)
- Simon B Ascher
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco
- Department of Medicine, University of California, Davis, Sacramento
| | - Rebecca Scherzer
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco
| | - Michelle M Estrella
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco
| | - Judy Shigenaga
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco
| | - Kimberly A Spaulding
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco
| | | | | | | | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine
| | - Robert M Grant
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco
| | - Vasantha Jotwani
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco
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23
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Abstract
Purpose of Review Clinical trials have found that PrEP is highly effective in reducing risk of HIV acquisition across types of exposure, gender, PrEP regimens, and dosing schemes. Evidence is urgently needed to inform scale-up of PrEP to meet the ambitious WHO/UNAIDS prevention target of 3,000,000 individuals on PrEP by 2020. Recent Findings Successful models of delivering HIV services at scale evolved from years of formal research and programmatic evidence. These efforts produced lessons-learned relevant for scaling-up PrEP delivery, including the importance of streamlining laboratory tests, expanding prescription and management authority, differentiating medication access points, and reducing stigma and barriers of parental consent for PrEP uptake. Further research is especially needed in areas differentiating PrEP from ART delivery, including repeat HIV testing to ensure HIV negative status and defining and measuring prevention-effective adherence. Summary Evidence from 15 years of ART scale-up could immediately inform a public health approach to PrEP delivery.
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24
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Liegeon G, Antoni G, Pialoux G, Capitant C, Cotte L, Charreau I, Tremblay C, Cua E, Senneville E, Raffi F, Meyer L, Molina J. Changes in kidney function among men having sex with men starting on demand tenofovir disoproxil fumarate - emtricitabine for HIV pre-exposure prophylaxis. J Int AIDS Soc 2020; 23:e25420. [PMID: 32086878 PMCID: PMC7035456 DOI: 10.1002/jia2.25420] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/02/2019] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Daily pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) is associated with a small but statistically significant decrease in estimated glomerular filtration rate (eGFR). We assessed the renal safety of on-demand PrEP with TDF/FTC in HIV-1 uninfected men. METHODS We used data from the randomized double-blind placebo-controlled ANRS-IPERGAY trial and its open-label extension conducted between February 2012 and June 2016 among HIV-uninfected MSM starting on-demand PrEP. Using linear mixed model, we evaluated the mean eGFR decline from baseline over time and determined risks factors associated with eGFR decline during the study. RESULTS During the blind phase, with a median follow-up of 9.4 months, the mean decline slope of eGFR from baseline was -0.88 and -1.53 mL/min/1.73 m2 per year in the placebo (n = 201) and the TDF/FTC group (n = 198) respectively, with a slope difference of 0.65 mL/min/1.73 m2 per year (p = 0.27). Including both phases, 389 participants started on-demand TDF/FTC with a median follow-up of 19.2 months and a mean decline of eGFR from baseline of -1.14 mL/min/1.73 m2 per year (p < 0.001). The slope of eGFR reduction was not significantly different in participants with baseline eGFR ≤ 90 mL/min/1.73 m2 (p = 0.44), age >40 years (p = 0.24) or hypertension (p = 0.21). There was a dose-response relationship between recent tenofovir exposure and lower eGFR when considering the number of pills taken in the two months prior the visit (eGFR difference of -0.88 mL/min/1.73 m2 between >15 pills/month vs. ≤15 pills/month, p < 0.01) or plasma tenofovir concentrations at the visit (eGFR difference compared to ≤2 ng/mL: >2 to ≤10ng/mL: -0.98 mL/min/1.73 m2 , >10 to ≤40ng/mL: -1.28 mL/min/1.73 m2 , >40 ng/mL: -1.82 mL/min/1.73 m2 , p < 0.001). Three participants discontinued TDF/FTC for eGFR < 60 mL/min/1.73 m2 during the OLE phase. No case of Fanconi syndrome was reported. CONCLUSIONS The renal safety of on-demand PrEP with TDF/FTC was good. The overall reduction and intermittent exposure to TDF/FTC may explain this good renal safety.
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Affiliation(s)
- Geoffroy Liegeon
- Hôpital Saint‐LouisAssistance Publique Hôpitaux de ParisParisFrance
| | | | | | | | - Laurent Cotte
- Hôpital de la Croix RousseHospices Civils de LyonLyonFrance
| | | | - Cécile Tremblay
- Centre Hospitalier de l'Université de MontréalMontréalCanada
| | | | - Eric Senneville
- Hôpital G. DronCentre Hospitalier Universitaire de TourcoingTourcoingFrance
| | - François Raffi
- INSERM UIC 143 Nantes UniversityNantesFrance
- Services des Maladies infectieusesCentre hospitalier universitaire de l'Hôtel‐DieuNantesFrance
| | - Laurence Meyer
- INSERMVillejuifFrance
- Université Paris SudParis SaclayFrance
| | - Jean‐Michel Molina
- Hôpital Saint‐LouisAssistance Publique Hôpitaux de ParisParisFrance
- Université de Paris Diderot Paris 7Sorbonne Paris CitéParisFrance
- INSERM UMR 944ParisFrance
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Turner D, Drak D, O’Connor CC, Templeton DJ, Gracey DM. Renal function change after switching tenofovir disoproxil fumarate for tenofovir alafenamide in the HIV-positive patients of a metropolitan sexual health service. AIDS Res Ther 2019; 16:40. [PMID: 31810490 PMCID: PMC6898922 DOI: 10.1186/s12981-019-0256-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 11/28/2019] [Indexed: 12/05/2022] Open
Abstract
Background Tenofovir disoproxil fumarate (TDF) is widely used in the management of HIV-infection, but has been associated with renal impairment in a small proportion of patients. Tenofovir alafenamide (TAF), a novel prodrug of tenofovir, causes less renal impairment and can improve renal function in patients switched from TDF. The factors which predict improved renal function in patients switching from TDF to TAF have yet to be described. Aim To determine which patient factors are associated with an improvement in renal function following the switch from a TDF- to a TAF-based HIV antiretroviral regimen. Methods A retrospective analysis was performed of a cohort from a publicly funded sexual health clinic in Sydney, Australia. All HIV-positive clinic patients switched from a TDF- to TAF-containing regimen between January 2016 and August 2018 were eligible for inclusion. Laboratory results were obtained from patients’ electronic medical records. The statistical significance of differences between pre- and post-switch means was determined by paired t-tests, adjusted for baseline values, and associations between continuous variables by univariate linear regression. Results 79 patients met inclusion criteria. The majority were male (89%), with a median age of 44 years (IQR: 34.5 to 53). Patients had a mean pre-switch estimated glomerular filtration rate (eGFR) of 95 ± 2 mL/min/1.73 m2, and there was no significant change post-switch (p = 0.062). Pre-switch eGFR was a significant predictor of the magnitude of eGFR change after the switch (p < 0.001), but there was no significant association with age (p = 0.189), cumulative TDF exposure (p = 0.454) or baseline urinary protein to creatinine ratio (p = 0.814). Conclusion While there was no significant difference in mean eGFR, in patients switched from TDF to TAF, baseline eGFR was a significant predictor of the change in eGFR. This suggests that patients on TDF with poorer baseline renal function would benefit more from switching to TAF. Further study to explore this association is warranted.
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Straub DM, Mullins TLK. Nonoccupational Postexposure Prophylaxis and Preexposure Prophylaxis for Human Immunodeficiency Virus Prevention in Adolescents and Young Adults. Adv Pediatr 2019; 66:245-261. [PMID: 31230697 DOI: 10.1016/j.yapd.2019.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Diane M Straub
- Division of Adolescent Medicine, University of South Florida, 2 Tampa General Circle, Suite 500, Tampa, FL 33606, USA.
| | - Tanya L Kowalczyk Mullins
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 4000, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
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Ortblad KF, Kearney JE, Mugwanya K, Irungu EM, Haberer JE, Barnabas RV, Donnell D, Mugo NR, Baeten JM, Ngure K. HIV-1 self-testing to improve the efficiency of pre-exposure prophylaxis delivery: a randomized trial in Kenya. Trials 2019; 20:396. [PMID: 31272495 PMCID: PMC6610957 DOI: 10.1186/s13063-019-3521-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 06/11/2019] [Indexed: 12/18/2022] Open
Abstract
Background The introduction of pre-exposure prophylaxis (PrEP) for human immunodeficiency virus-1 (HIV-1) prevention in Africa presents new challenges for health systems that are already overburdened because PrEP delivery requires frequent clinic visits (generally every 3 months) for HIV-1 testing and PrEP refills. HIV-1 self-testing (HIVST) has the potential to improve the efficiency of PrEP delivery by decreasing the number of clinic visits. Here, we describe the rationale and design of a randomized, noninferiority trial designed to test the effectiveness and safety of using HIVST to support PrEP delivery in Kenya. Methods The JiPime-JiPrEP (Kiswahili for ‘Test Yourself, PrEP Yourself’) study is a three-arm randomized trial taking place in Thika, Kenya. Participants (n = 495) are eligible for enrollment if they are at least 18 years old, HIV-1 seronegative, and have been taking PrEP for 1 month. Three distinct participant types will be enrolled: men (n = 165) and women (n = 165) who are in mutually disclosed HIV-1 serodiscordant relationships, and women (n = 165) who are at HIV-1 risk and not in a known serodiscordant relationship. Participants in each of these subpopulations will be 1:1:1 randomized to: 1) the standard of care, with quarterly clinic visits; 2) oral HIVST, with biannual clinic visits plus oral HIVSTs to use at the quarters between those visits; or 3) blood-based HIVST, with biannual clinic visits plus blood-based HIVSTs. All participants will complete quantitative surveys and provide blood samples for the objective measurement of PrEP adherence at baseline, 6 months, and 12 months. The primary outcomes are PrEP adherence, PrEP continuation, and HIV-1 testing, measured at 6 months and secondarily at 12 months. Discussion The findings from this trial can help to understand how HIVST—a new HIV-1 testing technology—can support health systems in sub-Saharan Africa. Additionally, the findings can inform policy aimed at improving the efficiency of PrEP implementation and scale-up in Kenya. Trial registration ClinicalTrials.gov, NCT03593629. Retrospectively registered on 20 July 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3521-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katrina F Ortblad
- Department of Global Health, University of Washington, 908 Jefferson St, Seattle, WA, 98104, USA.
| | - John E Kearney
- Department of Global Health, University of Washington, 908 Jefferson St, Seattle, WA, 98104, USA
| | - Kenneth Mugwanya
- Department of Global Health, University of Washington, 908 Jefferson St, Seattle, WA, 98104, USA
| | - Elizabeth M Irungu
- Department of Global Health, University of Washington, 908 Jefferson St, Seattle, WA, 98104, USA
| | - Jessica E Haberer
- Massachusetts General Hospital, Boston, USA.,Harvard Medical School, Boston, USA
| | - Ruanne V Barnabas
- Department of Global Health, University of Washington, 908 Jefferson St, Seattle, WA, 98104, USA.,Department of Medicine, University of Washington, Seattle, USA
| | - Deborah Donnell
- Department of Global Health, University of Washington, 908 Jefferson St, Seattle, WA, 98104, USA.,Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Nelly Rwamba Mugo
- Department of Global Health, University of Washington, 908 Jefferson St, Seattle, WA, 98104, USA.,Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jared M Baeten
- Department of Global Health, University of Washington, 908 Jefferson St, Seattle, WA, 98104, USA.,Department of Medicine, University of Washington, Seattle, USA.,Department of Epidemiology, University of Washington, Seattle, USA
| | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
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Kamis KF, Marx GE, Scott KA, Gardner EM, Wendel KA, Scott ML, Montgomery AE, Rowan SE. Same-Day HIV Pre-Exposure Prophylaxis (PrEP) Initiation During Drop-in Sexually Transmitted Diseases Clinic Appointments Is a Highly Acceptable, Feasible, and Safe Model that Engages Individuals at Risk for HIV into PrEP Care. Open Forum Infect Dis 2019; 6:ofz310. [PMID: 31341933 PMCID: PMC6641790 DOI: 10.1093/ofid/ofz310] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/26/2019] [Indexed: 11/18/2022] Open
Abstract
Objective Strategies to increase pre-exposure prophylaxis (PrEP) uptake are needed. We hypothesized that same-day PrEP initiation in a sexually transmitted diseases (STD) clinic would be acceptable, feasible, and safe, and that individuals would engage in ongoing PrEP care. Method Individuals aged ≥ 18 years were evaluated for PrEP. Exclusion criteria were HIV, history of renal dysfunction or chronic hepatitis B infection, pregnancy, indications for HIV post-exposure prophylaxis, or positive screen for acute HIV symptoms. One hundred individuals received a free 30-day PrEP starter pack and met with a patient navigator to establish ongoing care. Bivariate analysis and multivariable logistic regression were used to compare individuals who did and did not attend at least 1 PrEP follow-up appointment within 180 days of enrollment. Client satisfaction surveys were given 3 months after enrollment. Results The majority (78%) of participants completed at least 1 PrEP follow-up appointment, and 57% attended at least 2 follow-up appointments. After adjusting for race and ethnicity, age, health insurance status, and annual income, only income was associated with follow-up appointment attendance. Each additional $10,000 increase in income was associated with a 1.7-fold increase in the odds of attending a PrEP follow-up appointment (95% confidence interval, 1.07–2.66, P = .02). The majority (54%) of individuals completed the satisfaction survey and all respondents liked the option of same-day PrEP initiation. Conclusions Our study suggests STD clinic-based, same-day PrEP initiation is acceptable, feasible, safe, and links a high proportion of individuals into ongoing PrEP care. Additional resources may be needed to support low-income individuals’ retention in care.
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Affiliation(s)
- Kevin F Kamis
- Denver Public Health, Denver Health and Hospital Authority, Colorado
| | - Grace E Marx
- University of Colorado, Department of Medicine, Division of Infectious Diseases, Aurora.,Colorado School of Public Health, Department of Epidemiology, Aurora
| | - Kenneth A Scott
- Denver Public Health, Denver Health and Hospital Authority, Colorado
| | - Edward M Gardner
- Denver Public Health, Denver Health and Hospital Authority, Colorado.,University of Colorado, Department of Medicine, Division of Infectious Diseases, Aurora
| | - Karen A Wendel
- Denver Public Health, Denver Health and Hospital Authority, Colorado.,University of Colorado, Department of Medicine, Division of Infectious Diseases, Aurora
| | | | | | - Sarah E Rowan
- Denver Public Health, Denver Health and Hospital Authority, Colorado.,University of Colorado, Department of Medicine, Division of Infectious Diseases, Aurora
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Heendeniya A, Bogoch II. Antiretroviral Medications for the Prevention of HIV Infection: A Clinical Approach to Preexposure Prophylaxis, Postexposure Prophylaxis, and Treatment as Prevention. Infect Dis Clin North Am 2019; 33:629-646. [PMID: 31239092 DOI: 10.1016/j.idc.2019.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Preventing new human immunodeficiency virus (HIV) infections is essential to halting the global pandemic. HIV prevention strategies include integrating both nonpharmacologic (eg, safe sexual counseling, circumcision) and pharmacologic approaches. Several pharmacologic HIV prevention strategies are increasingly used globally and include postexposure prophylaxis, preexposure prophylaxis, and treatment as prevention. These prevention modalities have enormous clinical and public health appeal, as they effectively reduce HIV acquisition in individuals and also may lower HIV incidence in communities when integrated and implemented broadly. Efforts are now underway to scale HIV prevention programs using these techniques in both high- and low-resource settings.
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Affiliation(s)
- Amila Heendeniya
- Division of Infectious Diseases, Toronto General Hospital, Toronto General Hospital, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Isaac I Bogoch
- Division of Infectious Diseases, Toronto General Hospital, Toronto General Hospital, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada; Department of Medicine, University of Toronto, 190 Elizabeth Street, R. Fraser Elliott Building, 3-805, Toronto, Ontario M5G 2C4, Canada; Division of General Internal Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
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30
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Yap PK, Loo Xin GL, Tan YY, Chellian J, Gupta G, Liew YK, Collet T, Dua K, Chellappan DK. Antiretroviral agents in pre-exposure prophylaxis: emerging and advanced trends in HIV prevention. ACTA ACUST UNITED AC 2019; 71:1339-1352. [PMID: 31144296 DOI: 10.1111/jphp.13107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 05/05/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Antiretroviral agents (ARVs) have been the most promising line of therapy in the management of human immunodeficiency virus (HIV) infections. Some of these ARVs are used in the pre-exposure prophylaxis (PrEP) to suppress the transmission of HIV. Prophylaxis is primarily used in uninfected people, before exposure, to effectively prevent HIV infection. Several studies have shown that ART PrEP prevents HIV acquisition from sexual, blood and mother-to-child transmissions. However, there are also several challenges and limitations to PrEP. This review focuses on the current antiretroviral therapies used in PrEP. KEY FINDINGS Among ARVs, the most common drugs employed from the class of entry inhibitors are maraviroc (MVC), which is a CCR5 receptor antagonist. Other entry inhibitors like emtricitabine (FTC) and tenofovir (TFV) are also used. Rilpivirine (RPV) and dapivirine (DPV) are the most common drugs employed from the Non-nucleoside reverse transcriptase inhibitor (NNRTIs) class, whereas, tenofovir disoproxil fumarate (TDF) is primarily used in the Nucleoside Reverse Transcriptase Inhibitor (NRTIs) class. Cabotegravir (CAB) is an analog of dolutegravir, and it is an integrase inhibitor. Some of these drugs are also used in combination with other drugs from the same class. SUMMARY Some of the most common pre-exposure prophylactic strategies employed currently are the use of inhibitors, namely entry inhibitors, non-nucleoside reverse transcriptase inhibitors, nucleoside reverse transcriptase inhibitors, integrase and protease inhibitors. In addition, we have also discussed on the adverse effects caused by ART in PrEP, pharmacoeconomics factors and the use of antiretroviral prophylaxis in serodiscordant couples.
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Affiliation(s)
- Pui Khee Yap
- School of Health Sciences, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Griselda Lim Loo Xin
- School of Health Sciences, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Yoke Ying Tan
- School of Health Sciences, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Jestin Chellian
- Department of Life Sciences, School of Pharmacy, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Gaurav Gupta
- School of Pharmacy, Suresh Gyan Vihar University, Jaipur, India
| | - Yun Khoon Liew
- Department of Life Sciences, School of Pharmacy, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Trudi Collet
- Innovative Medicines Group, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Qld, Australia
| | - Kamal Dua
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney (UTS), Ultimo, NSW, Australia.,Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute (HMRI) & School of Biomedical Sciences and Pharmacy, The University of Newcastle (UoN), Callaghan, NSW, Australia
| | - Dinesh Kumar Chellappan
- Department of Life Sciences, School of Pharmacy, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
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Pre-exposure Prophylaxis With Tenofovir Disoproxil Fumarate/Emtricitabine and Kidney Tubular Dysfunction in HIV-Uninfected Individuals. J Acquir Immune Defic Syndr 2019; 78:169-174. [PMID: 29767638 PMCID: PMC6071417 DOI: 10.1097/qai.0000000000001654] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) is becoming increasingly adopted for HIV prevention. Tenofovir can cause proximal tubular damage and chronic kidney disease in HIV-infected persons, but little is known regarding its nephrotoxic potential among HIV-uninfected persons. In this study, we evaluated the effects of PrEP on urine levels of the following: α1-microglobulin (α1m), a marker of impaired tubular reabsorption; albuminuria, a measure of glomerular injury; and total proteinuria. SETTING The Iniciativa Profilaxis Pre-Exposicion (iPrEx) study randomized HIV-seronegative men and transgender women who have sex with men to oral TDF/FTC or placebo. The iPrEx open-label extension (iPrEx-OLE) study enrolled former PrEP trial participants to receive open-label TDF/FTC. METHODS A cross-sectional analysis compared urine biomarker levels by study arm in iPrEx (N = 100 treatment arm, N = 100 placebo arm). Then, urine biomarker levels were compared before and after PrEP initiation in 109 participants of iPrEx-OLE. RESULTS In iPrEx, there were no significant differences in urine α1m, albuminuria, or proteinuria by treatment arm. In iPrEx-OLE, after 24 weeks on PrEP, urine α1m and proteinuria increased by 21% [95% confidence interval (CI): 10 to 33] and 18% (95% CI: 8 to 28), respectively. The prevalence of detectable α1m increased from 44% to 65% (P < 0.001) and estimated glomerular filtration rate declined by 4 mL/min/1.73 m (P < 0.001). There was no significant change in albuminuria (6%; 95% CI: -7% to 20%). CONCLUSION PrEP with TDF/FTC was associated with a statistically significant rise in urine α1m and proteinuria after 6 months, suggesting that PrEP may result in subclinical tubule dysfunction.
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Pre-exposure Prophylaxis for HIV Infection in the Older Patient: What can be Recommended? Drugs Aging 2019; 35:485-491. [PMID: 29736816 DOI: 10.1007/s40266-018-0553-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Over the past 15 years, a significant increase in new HIV/AIDS diagnoses has been observed in the elderly population. This new epidemiological shift has been attributed to a longer sex life, lifestyle and changes in sexual behavior, poor sexual health education, and misconceptions about the absence of sexually transmitted disease in later life. Although many biomedical and behavioral interventions have proven useful to prevent sexually transmitted infections and HIV, pre-exposure prophylaxis (PrEP) has been shown to be the most successful biomedical intervention to prevent HIV in high-risk individuals. This approach is based on delivering a fixed dose of tenofovir disoproxil fumarate (300 mg), alone or combined with emtricitabine (300/200 mg) daily or on demand, before and after sexual intercourse. Despite the consistent number of clinical trials proving the effectiveness and safety of this strategy, no studies have focused specifically on elderly people. These individuals, who may benefit substantially from (PrEP), are at a higher risk of experiencing side effects secondary to tenofovir exposure. This review critically discusses the efficacy and safety of PrEP in people aged over 50 years and translates the knowledge of tenofovir management in patients with HIV into monitoring and stopping rules to be used in this special population. We provide practical recommendations to properly identify PrEP candidates among older adults. Furthermore, we define correct case management before and during PrEP delivery, and we suggest stopping rules and alternative sexually transmitted infection prevention strategies.
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Drak D, Barratt H, Templeton DJ, O’Connor CC, Gracey DM. Renal function and risk factors for renal disease for patients receiving HIV pre-exposure prophylaxis at an inner metropolitan health service. PLoS One 2019; 14:e0210106. [PMID: 30653509 PMCID: PMC6336260 DOI: 10.1371/journal.pone.0210106] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 12/17/2018] [Indexed: 12/26/2022] Open
Abstract
Background Pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) significantly reduces the risk of HIV acquisition. TDF is a known nephrotoxin however, renal dysfunction from TDF is mostly reversible following discontinuation. Aims To describe the renal function, risk factors for renal disease and associated clinical testing practices in a cohort of PrEP patients. Methods A retrospective review was conducted of all PrEP patients commenced on TDF/FTC at an inner metropolitan sexual health clinic in Sydney, Australia between April 2016 and July 2017, with follow-up data obtained at 3-monthly intervals until 18 months. Results 525 patients met inclusion criteria. Patients were almost exclusively male and median age was 34 years (IQR: 28 to 42). At baseline, 1.5% had an estimated glomerular filtration rate (eGFR) <70 mL/min/1.73m2. A small significant drop in eGFR of -2.5 mL/min/1.73m2 (p<0.05) occurred between PrEP commencement and the first follow-up period, followed by a progressive decline in eGFR of -0.38 mL/min/1.73m2 per month (95%CI: -0.57 to -0.20; p<0.001). Renal impairment (eGFR <70 mL/min/1.73m2) occurred in 6.5% of patients and persisted across consecutive follow-up periods in five (1.0%) patients. Patients aged ≥40 years had a greater risk of renal impairment than younger patients (HR 3.9, 95%CI: 1.8 to 8.4; p<0.001), despite similar rates of eGFR decline (p = 0.19). PrEP was discontinued in two patients (0.4%) due to renal function concerns. Conclusion PrEP use led to an initial drop in eGFR and a more gradual progressive decline subsequently, but significant renal impairment remained uncommon up to 18 months of follow-up.
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Affiliation(s)
- Douglas Drak
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- * E-mail:
| | - Hamish Barratt
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Central Clinical School, University of Sydney, Sydney, NSW, Australia
| | - David J. Templeton
- Central Clinical School, University of Sydney, Sydney, NSW, Australia
- RPA Sexual Health, Sydney Local Health District, Sydney, NSW, Australia
- Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Catherine C. O’Connor
- Central Clinical School, University of Sydney, Sydney, NSW, Australia
- RPA Sexual Health, Sydney Local Health District, Sydney, NSW, Australia
- Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - David M. Gracey
- Central Clinical School, University of Sydney, Sydney, NSW, Australia
- Renal Unit, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
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Pilkington V, Hill A, Hughes S, Nwokolo N, Pozniak A. How safe is TDF/FTC as PrEP? A systematic review and meta-analysis of the risk of adverse events in 13 randomised trials of PrEP. J Virus Erad 2018; 4:215-224. [PMID: 30515300 PMCID: PMC6248833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Tenofovir/emtricitabine (TDF/FTC) used as pre-exposure prophylaxis (PrEP) has proven benefits in preventing HIV infection. Widespread use of TDF/FTC can only be justified if the preventative benefits outweigh potential risks of adverse events. A previous meta-analysis of TDF/FTC compared to alternative tenofovir alafenamide (TAF)/FTC for treatment found no significant difference in safety endpoints when used without ritonavir or cobicistat, but more evidence around the safety of TDF/FTC is needed to address concerns and inform widespread use. METHODS A systematic review identified 13 randomised trials of PrEP, using either TDF/FTC or TDF, versus placebo or no treatment: VOICE, PROUD, IPERGAY, FEM-PrEP, TDF-2, iPrEX, IAVI Kenya, IAVI Uganda, PrEPare, PARTNERS, US Safety study, Bangkok TDF study, W African TDF study. The number of participants with grade 3/4 adverse events or serious adverse events (SAEs) was compared between treatment and control in the meta-analysis. Further analyses of specific renal and bone markers were also undertaken, with fractures as a marker of bone effects and creatinine elevations as a surrogate marker for renal impairment. Analyses were stratified by study duration (</>1 year of follow up). RESULTS The 13 randomised trials included 15,678 participants in relevant treatment and control arms. Three studies assessed TDF use only. The number of participants with grade 3/4 adverse events was 1306/7504 (17.4%) on treatment versus 1259/7502 (16.8%) on control (difference=0%, 95% confidence interval [CI] -1% to +2%). The number of participants with SAEs was 740/7843 (9.4%) on treatment versus 795/7835 (10.1%) on no treatment (difference=0%, 95% CI -1% to +1%). The number of participants with creatinine elevations was 8/7843 on treatment versus 4/7835 on control (difference=0%, 95% CI 0%-0%). The number of participants with bone fractures was 217/5789 on treatment versus 189/5795 on control (difference=0%, 95% CI 0% to 1%). There was no difference in outcome between studies with <1 versus >1 year of randomised treatment. CONCLUSIONS In this meta-analysis of 13 randomised clinical trials of PrEP in 15,678 participants, there was no significant difference in risk of grade 3/4 clinical adverse events or SAEs between TDF/FTC (or TDF) and control. Furthermore, there was no significant difference in risk of specific renal or bone adverse outcomes. The favourable safety profile of TDF/FTC would support more widespread use PrEP in populations with a lower risk of HIV infection.
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Affiliation(s)
| | - Andrew Hill
- Department of Pharmacology and Therapeutics, University of Liverpool,
UK,Corresponding author: Andrew M Hill,
Department of
Translational Medicine,
University of Liverpool,
70 Pembroke Place,
LiverpoolL69 3GF,
UK.
| | | | - Nneka Nwokolo
- Chelsea and Westminster Hospital, 56 Dean Street,
LondonUK
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Pilkington V, Hill A, Hughes S, Nwokolo N, Pozniak A. How safe is TDF/FTC as PrEP? A systematic review and meta-analysis of the risk of adverse events in 13 randomised trials of PrEP. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30312-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Tan DHS, Schnubb A, Lawless J, Szadkowski L, Grennan T, Wilton J, Fowler S, Hart TA, Maxwell J, Raboud JM. Acceptability and tolerability of and adherence to HIV preexposure prophylaxis among Toronto gay and bisexual men: a pilot study. CMAJ Open 2018; 6:E611-E617. [PMID: 30530721 PMCID: PMC6287974 DOI: 10.9778/cmajo.20180068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Preexposure prophylaxis is efficacious at preventing HIV infection, but concerns persist about adherence and sexually transmitted infections (STIs). We assessed preexposure prophylaxis acceptability, adherence and clinical outcomes in a pilot demonstration project. METHODS HIV-uninfected adult gay and bisexual men who scored 10 or higher on a validated HIV risk score (HIV Incidence Risk Index for MSM) and reported condomless receptive anal sex were sequentially enrolled into a 1-year open-label single-arm pilot study of daily oral therapy with tenofovir disoproxil fumarate/emtricitabine in Toronto. The primary outcome was acceptability of preexposure prophylaxis. Secondary outcomes were preexposure prophylaxis adherence (4-d recall, pill count and dried blood spot analysis), HIV seroconversion, STIs and adverse events. RESULTS Of the 86 men screened, 52 were enrolled. Participants were mostly young (median age 33 yr [interquartile range (IQR) 28-37 yr) white (38 [73%]) gay (49 [94%]) men. Preexposure prophylaxis acceptability was high: all participants reported their experience as "good" or "very good." The median adherence rate was high, at 100% (IQR 95%-100%) by self-report and 96.9% (IQR 93.4%-98.4%) by pill count. Dried blood spot analysis suggested that doses were taken 4-7 days/week at 88.7% (173/195) of month 3-12 visits. No cases of HIV seroconversion occurred, but 25 participants (48%) experienced at least 1 bacterial STI, with incidence rates per 100 person-years of 32.8, 32.8, 8.2 and 8.2 for chlamydia, gonorrhea, syphilis and lymphogranuloma venereum, respectively. No adverse events led to discontinuation of prophylaxis, but the estimated glomerular filtration rate declined by 0.22 mL/min per month. INTERPRETATION Preexposure prophylaxis was associated with high adherence and acceptability and no HIV infections in this study. Frequent STIs and clinically unapparent toxic renal effects reinforce the need for ongoing vigilance. TRIAL REGISTRATION ClinicalTrials. gov, no. NCT02149888.
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Affiliation(s)
- Darrell H S Tan
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont.
| | - Alexandre Schnubb
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - James Lawless
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - Leah Szadkowski
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - Troy Grennan
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - James Wilton
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - Shawn Fowler
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - Trevor A Hart
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - John Maxwell
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - Janet M Raboud
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
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Mugwanya KK, Irungu E, Bukusi E, Mugo NR, Odoyo J, Wamoni E, Ngure K, Morton JF, Peebles K, Masyuko S, Barnabee G, Donnell D, Barnabas R, Haberer J, O'Malley G, Baeten JM. Scale up of PrEP integrated in public health HIV care clinics: a protocol for a stepped-wedge cluster-randomized rollout in Kenya. Implement Sci 2018; 13:118. [PMID: 30180860 PMCID: PMC6123996 DOI: 10.1186/s13012-018-0809-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 08/15/2018] [Indexed: 12/26/2022] Open
Abstract
Background Antiretroviral therapy (ART) for HIV-infected persons and pre-exposure prophylaxis (PrEP) for uninfected persons are extraordinarily effective strategies for HIV prevention. In Africa, the region which shoulders the highest HIV burden, HIV care is principally delivered through public health HIV care clinics, offering an existing platform to incorporate PrEP delivery and maximize ART and PrEP synergies. However, successfully bringing this integrated approach to scale requires an implementation science evaluation in public health settings. Methods The Partners Scale Up Project is a prospective, pragmatic implementation evaluation, designed as a stepped-wedge, cluster-randomized trial, operating at 24 clinics in Kenya. In collaboration with the Kenya Ministry of Health, we are catalyzing scaled implementation of PrEP delivery integrated in HIV care clinics. The intervention package includes staff training, clinic streamlined access to PrEP commodity from the Kenya Medical Supply Authority, and ongoing intensive technical assistance to rigorously assess how PrEP delivery is implemented. PrEP service delivery including retention efforts are conducted by the clinic staff with no additional resources from the project. Guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework and Consolidated Framework for Implementation Science Research, project progress and learning are documented through ongoing monitoring and process evaluations, including chart abstraction and individual and key informant interviews, to evaluate pragmatic rollout and understand barriers and facilitators for successful PrEP delivery in this setting. In this staged rollout design, each step provides data for both pre-implementation (baseline) and implementation periods, and we will compare time points across steps in the baseline versus implementation periods. Discussion Cost-effective delivery models are urgently needed to maximize the public health impact of PrEP and ART. The Partners Scale Up Project will set the stage for full-scale PrEP implementation fully run and owned by the Kenya Ministry of Health. The work combines nationally sponsored PrEP delivery with technical support and implementation science from academic partners, defining a new but sustainable paradigm for public health collaboration. Trial registration Registered with ClinicalTrials.gov on February 14, 2017:NCT03052010.
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Affiliation(s)
- Kenneth K Mugwanya
- Department of Global Health, University of Washington, 325 Ninth Avenue, #HMC 359927, Seattle, WA, 98104, USA.
| | | | - Elizabeth Bukusi
- Kenya Medical Research Institute, Nairobi, Kenya.,Department of Obstetrics and Gynecology, University of Washington, Seattle, USA
| | - Nelly R Mugo
- Department of Global Health, University of Washington, 325 Ninth Avenue, #HMC 359927, Seattle, WA, 98104, USA.,Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Kenneth Ngure
- Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Jennifer F Morton
- Department of Global Health, University of Washington, 325 Ninth Avenue, #HMC 359927, Seattle, WA, 98104, USA
| | - Kathryn Peebles
- Department of Global Health, University of Washington, 325 Ninth Avenue, #HMC 359927, Seattle, WA, 98104, USA
| | - Sarah Masyuko
- National AIDS and STI Control Program Ministry of Health, Nairobi, Kenya
| | - Gena Barnabee
- Department of Global Health, University of Washington, 325 Ninth Avenue, #HMC 359927, Seattle, WA, 98104, USA
| | - Deborah Donnell
- Department of Global Health, University of Washington, 325 Ninth Avenue, #HMC 359927, Seattle, WA, 98104, USA.,Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Ruanne Barnabas
- Departments of Global Health and Medicine, University of Washington, Seattle, USA
| | | | - Gabrielle O'Malley
- Department of Global Health, University of Washington, 325 Ninth Avenue, #HMC 359927, Seattle, WA, 98104, USA
| | - Jared M Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, USA
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Saag MS, Benson CA, Gandhi RT, Hoy JF, Landovitz RJ, Mugavero MJ, Sax PE, Smith DM, Thompson MA, Buchbinder SP, Del Rio C, Eron JJ, Fätkenheuer G, Günthard HF, Molina JM, Jacobsen DM, Volberding PA. Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2018 Recommendations of the International Antiviral Society-USA Panel. JAMA 2018; 320:379-396. [PMID: 30043070 PMCID: PMC6415748 DOI: 10.1001/jama.2018.8431] [Citation(s) in RCA: 440] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance Antiretroviral therapy (ART) is the cornerstone of prevention and management of HIV infection. Objective To evaluate new data and treatments and incorporate this information into updated recommendations for initiating therapy, monitoring individuals starting therapy, changing regimens, and preventing HIV infection for individuals at risk. Evidence Review New evidence collected since the International Antiviral Society-USA 2016 recommendations via monthly PubMed and EMBASE literature searches up to April 2018; data presented at peer-reviewed scientific conferences. A volunteer panel of experts in HIV research and patient care considered these data and updated previous recommendations. Findings ART is recommended for virtually all HIV-infected individuals, as soon as possible after HIV diagnosis. Immediate initiation (eg, rapid start), if clinically appropriate, requires adequate staffing, specialized services, and careful selection of medical therapy. An integrase strand transfer inhibitor (InSTI) plus 2 nucleoside reverse transcriptase inhibitors (NRTIs) is generally recommended for initial therapy, with unique patient circumstances (eg, concomitant diseases and conditions, potential for pregnancy, cost) guiding the treatment choice. CD4 cell count, HIV RNA level, genotype, and other laboratory tests for general health and co-infections are recommended at specified points before and during ART. If a regimen switch is indicated, treatment history, tolerability, adherence, and drug resistance history should first be assessed; 2 or 3 active drugs are recommended for a new regimen. HIV testing is recommended at least once for anyone who has ever been sexually active and more often for individuals at ongoing risk for infection. Preexposure prophylaxis with tenofovir disoproxil fumarate/emtricitabine and appropriate monitoring is recommended for individuals at risk for HIV. Conclusions and Relevance Advances in HIV prevention and treatment with antiretroviral drugs continue to improve clinical management and outcomes for individuals at risk for and living with HIV.
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Affiliation(s)
| | | | - Rajesh T Gandhi
- Massachusetts General Hospital and Harvard Medical School, Boston
| | - Jennifer F Hoy
- The Alfred Hospital and Monash University, Melbourne, Australia
| | | | | | - Paul E Sax
- Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | - Susan P Buchbinder
- San Francisco Department of Public Health and University of California San Francisco
| | - Carlos Del Rio
- Emory University Rollins School of Public Health and School of Medicine, Atlanta, Georgia
| | - Joseph J Eron
- University of North Carolina at Chapel Hill School of Medicine
| | - Gerd Fätkenheuer
- University Hospital of Cologne, Department I of Internal Medicine, Cologne, Germany, and German Center for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - Huldrych F Günthard
- University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
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Chan L, Asriel B, Eaton EF, Wyatt CM. Potential kidney toxicity from the antiviral drug tenofovir: new indications, new formulations, and a new prodrug. Curr Opin Nephrol Hypertens 2018; 27:102-112. [PMID: 29278542 PMCID: PMC6103211 DOI: 10.1097/mnh.0000000000000392] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW The antiviral agent tenofovir is highly effective for the treatment of HIV and hepatitis B virus infections, and the older prodrug tenofovir disoproxil fumarate (TDF) is also a component of daily preexposure prophylaxis (PrEP) to reduce the risk of HIV infection in high-risk populations. Although TDF is well tolerated, the potential for kidney and bone toxicity has important implications for public health given the large number of individuals exposed to TDF worldwide. This review summarizes the recent literature on kidney and bone health in individuals treated with TDF and the newer prodrug tenofovir alafenamide (TAF). RECENT FINDINGS Risk factors for TDF toxicity appear to be similar in patients treated for HIV or hepatitis B virus and in HIV-uninfected PrEP users, although drug-drug interactions are a more important concern in HIV-positive individuals. The risk of toxicity appears to be lower with TAF, but further studies are needed to confirm the safety of long-term use and to evaluate the efficacy of TAF-based PrEP. SUMMARY Nephrologists should be aware of the potential kidney and bone toxicity of TDF, as well as unique situations in which the newer prodrug TAF may contribute to kidney injury.
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Affiliation(s)
- Lili Chan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Benjamin Asriel
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ellen F Eaton
- Division of Infectious Diseases, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Christina M Wyatt
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Rajchgot J, Siemieniuk RAC, Sivachandran N, Murphy P, Sharp A, Cicci A, Bogoch II. Feasibility of HIV Pre-Exposure Prophylaxis as Part of Routine Care in Toronto, Canada. J Acquir Immune Defic Syndr 2018; 72:e80-1. [PMID: 27035886 DOI: 10.1097/qai.0000000000001004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jason Rajchgot
- *Department of Medicine, University of Toronto, Toronto, ON, Canada †Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada ‡Immunodeficiency Clinic, Toronto General Hospital, Toronto, ON, Canada §Divisions of Internal Medicine and Infectious Diseases, University Health Network, Toronto, ON, Canada
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Siguier M, Molina JM. HIV preexposure prophylaxis: An essential, safe and effective prevention tool for sexual health. Med Mal Infect 2018; 48:318-326. [PMID: 29433965 DOI: 10.1016/j.medmal.2018.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 01/17/2018] [Indexed: 01/26/2023]
Abstract
Preexposure prophylaxis of HIV with antiretroviral drugs is a prevention tool available in France since 2016, combined with the prevention methods already used (condoms, post-exposure treatment, rapid treatment of diagnosed HIV infections, etc.). It is targeted at populations at high risk of HIV infection, especially men who have sex with men, for whom traditional prevention methods are insufficient. We collected clinical research data, which resulted in the launch of preexposure prophylaxis in the United States and then elsewhere in the world, safety, tolerability and cost data, as well as ongoing research data (new molecules/methods of administration). We also provided an update of its use in France.
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Affiliation(s)
- M Siguier
- Service de maladies infectieuses et tropicales, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 1, avenue Claude-Vellefaux, 75010 Paris, France; Université Paris-Diderot, 5, rue Thomas-Mann, 75013 Paris, France.
| | - J-M Molina
- Service de maladies infectieuses et tropicales, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 1, avenue Claude-Vellefaux, 75010 Paris, France; Université Paris-Diderot, 5, rue Thomas-Mann, 75013 Paris, France
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Mugwanya KK, Baeten JM, Wyatt C, Mugo NR, Celum CL, Ronald A, Kiarie J, Katabira E, Heffron R. Brief Report: Frequency of Monitoring Kidney Function in HIV-Uninfected Persons Using Daily Oral Tenofovir Disoproxil Fumarate Pre-exposure Prophylaxis. J Acquir Immune Defic Syndr 2018; 77:206-211. [PMID: 29135656 PMCID: PMC5762271 DOI: 10.1097/qai.0000000000001575] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Wide-scale implementation of oral tenofovir-based pre-exposure prophylaxis (PrEP) for HIV prevention is now policy in many settings. However, the optimal frequency for monitoring kidney function remains uncertain. We investigated the impact of 6-monthly compared with 3-monthly creatinine clearance (CrCl) monitoring on the identification of moderate kidney dysfunction, defined as CrCl <60 mL/min. METHODS Data were from 2 prospective daily oral PrEP studies in Kenya and Uganda: the Partners PrEP Study, a randomized safety, and efficacy trial of PrEP that conducted 3-monthly CrCl monitoring (n = 4404) and the Partners Demonstration Project (n = 954), an open-label delivery study of PrEP that used 6-monthly monitoring. CrCl ≥60 mL/min was required for enrollment in both studies. Abnormal results were followed with confirmatory testing within approximately 1 week. Follow-up was for up to 24 months. RESULTS Of 5358 participants included in the analysis, 87% were younger than 45 years, a third were female, and 21% had a baseline CrCl between 60 and 90 mL/min. Confirmed CrCl <60 mL/min events were rare, occurring in 52 individuals (<1%) in 24 months. The 12-month cumulative proportion of persons with CrCl <60 mL/min was 0.2% with 3-monthly screening and 0.5% with 6-monthly screening. Older age (>45 years), lower weight (<55 kg), elevated blood pressure (>140 mm Hg), and baseline CrCl between 60 and 90 mL/min were independently associated with CrCl decline <60 mL/min during follow-up. CONCLUSIONS In these 2 PrEP studies, with generally young participants, the occurrence and pattern of clinically relevant decline in CrCl were not qualitatively different based on 3- or 6-monthly CrCl monitoring schedule. These data suggest that for most persons receiving PrEP for up to 24 months, less frequent CrCl monitoring would be safe and reduce required expenditures for repeat confirmatory testing.
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Affiliation(s)
- Kenneth K Mugwanya
- Department of Global Health, University of Washington, Seattle, WA
- Division of Disease Control, School of Public Health, Makerere University, Kampala, Uganda
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA
- Medicine, University of Washington, Seattle, WA
| | - Christina Wyatt
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nelly R Mugo
- Department of Global Health, University of Washington, Seattle, WA
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Connie L Celum
- Department of Global Health, University of Washington, Seattle, WA
- Medicine, University of Washington, Seattle, WA
| | - Allan Ronald
- Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - John Kiarie
- Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya
| | - Elly Katabira
- Department of Medicine, Makerere University, Kampala, Kenya
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, WA
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Tang EC, Vittinghoff E, Anderson PL, Cohen SE, Doblecki-Lewis S, Bacon O, Coleman ME, Buchbinder SP, Chege W, Kolber MA, Elion R, Shlipak M, Liu AY. Changes in Kidney Function Associated With Daily Tenofovir Disoproxil Fumarate/Emtricitabine for HIV Preexposure Prophylaxis Use in the United States Demonstration Project. J Acquir Immune Defic Syndr 2018; 77:193-198. [PMID: 28991887 PMCID: PMC5762266 DOI: 10.1097/qai.0000000000001566] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND HIV preexposure prophylaxis (PrEP) using daily oral tenofovir-disoproxil-fumarate/emtricitabine (TDF/FTC) is effective for preventing HIV acquisition, but concerns remain about its potential kidney toxicity. This study examined kidney function in individuals using PrEP in real-world clinical settings. SETTING Demonstration project in 2 sexually transmitted infection clinics and a community health center. METHODS We evaluated kidney function among men who have sex with men and transgender women taking tenofovir-disoproxil-fumarate/emtricitabine PrEP for up to 48 weeks. Serum creatinine and urine dipstick for protein were obtained at 12-week intervals. Kidney function was estimated using creatinine clearance (CrCl) (Cockcroft-Gault) and estimated glomerular filtration rate (eGFR) (CKD-EPI). RESULTS From October 2012 to January 2014, we enrolled 557 participants (median age 33). Mean creatinine increased from baseline to week 12 by 0.03 mg/dL (4.6%) (P < 0.0001); mean CrCl decreased by 4.8 mL/min (3.0%) (P < 0.0001). These changes remained stable through week 48 (P = 0.81, P = 0.71 respectively). There were 75/478 (15.7%) participants who developed worsening proteinuria at week 12 compared with baseline (P < 0.0001), and this percent remained stable through week 48 (P = 0.73). Twenty-five participants (5.1%) developed new-onset eGFR <70 mL/min/1.73 m; independent predictors of this outcome were age ≥40 years (OR 3.79, 95% CI: 1.43 to 10.03) and baseline eGFR <90 mL/min/1.73 m (OR 9.59, 3.69-24.94). CONCLUSIONS In a demonstration setting, daily tenofovir-disoproxil-fumarate/emtricitabine PrEP leads to reduced CrCl and eGFR; however, these eGFR changes are based on very small changes in serum creatinine and seem to be nonprogressive after the first 12 weeks. Future studies are needed to understand the prognostic significance of these small changes.
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Affiliation(s)
- Eric C Tang
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | - Peter L Anderson
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Stephanie E Cohen
- San Francisco Departments of Public Health and Medicine, University of California San Francisco, San Francisco, USA
| | - Susanne Doblecki-Lewis
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL
| | - Oliver Bacon
- San Francisco Department of Public Health, Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA
| | | | - Susan P Buchbinder
- Bridge HIV, San Francisco Department of Public Health
- Departments of Medicine, Epidemiology and Biostatistics, University of California, San Francisco San Francisco, CA
| | - Wairimu Chege
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Michael A Kolber
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Richard Elion
- Providence Hospital Department of Infectious Disease, George Washington University School of Medicine, Washington, DC
| | - Michael Shlipak
- Kidney Health Research Collaborative, San Francisco VA Medical Center, University of California, San Francisco, San Francisco, CA
| | - Albert Y Liu
- Bridge HIV, San Francisco Department of Public Health
- Department of Medicine, University of California, San Francisco, CA
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Achhra AC, Nugent M, Mocroft A, Ryom L, Wyatt CM. Chronic Kidney Disease and Antiretroviral Therapy in HIV-Positive Individuals: Recent Developments. Curr HIV/AIDS Rep 2017; 13:149-57. [PMID: 27130284 DOI: 10.1007/s11904-016-0315-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chronic kidney disease (CKD) has emerged as an important health concern in HIV-positive individuals. Preventing long-term kidney toxicity from an antiretroviral therapy is therefore critical. Selected antiretroviral agents, especially tenofovir disoproxil fumarate (TDF) and some ritonavir-boosted protease inhibitors (PI/rs), have been associated with increased risk of CKD. However, the CKD risk attributable to these agents is overall small, especially in those with low baseline risk of CKD and normal renal function. CKD risk in HIV-positive individuals can be further minimized by timely identification of those with worsening renal function and discontinuation of potentially nephrotoxic agents. Clinicians can use several monitoring tools, including the D:A:D risk score and routine measurements of estimated glomerular filtration (eGFR) and proteinuria, to identify high-risk individuals who may require an intervention. Tenofovir alafenamide (TAF), a TDF alternative, promises to be safer in terms of TDF-associated kidney and bone toxicity. While the short-term data on TAF does indicate lower eGFR decline and lower risk of proteinuria (vs. TDF), long-term data on renal safety of TAF are still awaited. Promising results have also emerged from recent trials on alternative dual-therapy antiretroviral regimens which exclude the nucleoside(tide) reverse transcriptase class as well as possibly the PI/rs, thereby reducing the drug burden, and possibly the toxicity. However, long-term safety or benefits of these dual-therapy regimens are still unclear and will need to be studied in future prospective studies. Finally, addressing risk factors such as hypertension and diabetes will continue to be important in this population.
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Affiliation(s)
| | - Melinda Nugent
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Lene Ryom
- Department of Infectious Diseases, CHIP, Section 8632 Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Abstract
Although pre-exposure prophylaxis (PrEP)-the use of antiretroviral drugs by non-infected people to prevent the acquisition of HIV-is a promising preventive option, important public health questions remain. Daily oral emtricitabine (FTC)-tenofovir disoproxil fumarate (TDF) is highly efficacious in preventing the acquisition of HIV in people at risk as a result of a range of different types of sexual exposure. There is good evidence of efficacy in women and men, and when men who have sex with men use event based dosing. Studies have been conducted in several countries and epidemics. Because adherence to this treatment varies greatly there are questions about its public health benefit. Oral FTC-TDF is extremely safe, with minimal impact on kidney, bone, or pregnancy outcomes, and there is no evidence that its effectiveness has been reduced by risk compensation during open label and programmatic follow-up. It is too early to assess the impact of this treatment on the incidence of sexually transmitted infections (STIs) at a population level. Many challenges remain. Access to pre-exposure prophylaxis is limited and disparities exist, including those governed by race and sex. Different pricing and access models need to be explored to avoid further widening inequalities. The optimal combination prevention program needs to be defined, and this will depend on local epidemiology, service provision, and cost effectiveness. This review updates the evidence base for pre-exposure prophylaxis regarding its effectiveness, safety, and risk compensation.
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Affiliation(s)
- Monica Desai
- HIV and STI Department, Public Health England, London NW9 5EQ, UK
| | - Nigel Field
- Centre for Molecular Epidemiology and Translational Research, University College London, London WC1E 6BT, UK
| | - Robert Grant
- University of California School of Medicine; Gladstone Institutes; San Francisco AIDS Foundation, San Francisco, CA 94115, USA
| | - Sheena McCormack
- MRC Clinical Trials Unit, University College London, London
- Chelsea and Westminster Hospital, London SW10 9BH
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46
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Jotwani V, Atta MG, Estrella MM. Kidney Disease in HIV: Moving beyond HIV-Associated Nephropathy. J Am Soc Nephrol 2017; 28:3142-3154. [PMID: 28784698 PMCID: PMC5661296 DOI: 10.1681/asn.2017040468] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
In developed countries, remarkable advances in antiretroviral therapy have transformed HIV infection into a chronic condition. As a result, HIV-associated nephropathy, the classic HIV-driven kidney lesion among individuals of African descent, has largely disappeared in these regions. However, HIV-positive blacks continue to have much higher rates of ESRD than HIV-positive whites, which could be attributed to the APOL1 renal risk variants. Additionally, HIV-positive individuals face adverse consequences beyond HIV itself, including traditional risk factors for CKD and nephrotoxic effects of antiretroviral therapy. Concerns for nephrotoxicity also extend to HIV-negative individuals using tenofovir disoproxil fumarate-based pre-exposure prophylaxis for the prevention of HIV infection. Therefore, CKD remains an important comorbid condition in the HIV-positive population and an emerging concern among HIV-negative persons receiving pre-exposure prophylaxis. With the improved longevity of HIV-positive individuals, a kidney transplant has become a viable option for many who have progressed to ESRD. Herein, we review the growing knowledge regarding the APOL1 renal risk variants in the context of HIV infection, antiretroviral therapy-related nephrotoxicity, and developments in kidney transplantation among HIV-positive individuals.
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Affiliation(s)
- Vasantha Jotwani
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco, California
- Department of Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, California; and
| | - Mohamed G Atta
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Michelle M Estrella
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco, California;
- Department of Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, California; and
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Reversal of Proximal Renal Tubular Dysfunction after Nucleotide Analogue Withdrawal in Chronic Hepatitis B. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4327385. [PMID: 29214169 PMCID: PMC5682049 DOI: 10.1155/2017/4327385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 10/03/2017] [Indexed: 02/06/2023]
Abstract
Aims Proximal renal tubular dysfunction (PRTD) is an infrequent complication after nucleotide analogue therapy. We evaluated the outcomes of PRTD and nephrotoxicity after nucleotide analogue withdrawal in chronic hepatitis B (CHB). Methods A longitudinal follow-up study was performed in patients with PRTD after nucleotide analogue discontinuation. Serum and urine were collected at baseline and every 3 months for one year. The fractional excretion of phosphate (PO4), uric acid (UA), and potassium and tubular maximal reabsorption rate of PO4 to glomerular filtration rate (TmPO4/GFR) were calculated. Renal losses were defined based on the criteria of substance losses. Subclinical PRTD and overt PRTD were diagnosed when 2 and ≥3 criteria were identified. Results Eight subclinical and eight overt PRTD patients were enrolled. After nucleotide analogue withdrawal, there were overall improvements in GFR, serum PO4, and UA. Renal loss of PO4, UA, protein, and β2-microglobulin reduced over time. At one year, complete reversal of PRTD was seen in 13 patients (81.2%). Improvements in PRTD were seen in all but one patient. Conclusion One year after nucleotide analogue withdrawal, PRTD was resolved in most patients. Changes in TmPO4/GFR, urinary protein, and β2-microglobulin indicate that urinary biomarkers may represent an early sign of PRTD recovery.
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48
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Kooij KW, Vogt L, Wit FWNM, van der Valk M, van Zoest RA, Goorhuis A, Prins M, Post FA, Reiss P. Higher Prevalence and Faster Progression of Chronic Kidney Disease in Human Immunodeficiency Virus-Infected Middle-Aged Individuals Compared With Human Immunodeficiency Virus-Uninfected Controls. J Infect Dis 2017; 216:622-631. [PMID: 28934420 DOI: 10.1093/infdis/jix202] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 05/07/2017] [Indexed: 01/22/2023] Open
Abstract
Background Human immunodeficiency virus (HIV)-infected individuals are at increased risk of chronic kidney disease (CKD). Human immunodeficiency virus infection, traditional CKD risk factors, and combination antiretroviral therapy (cART) may all contribute. Methods We compared prevalence of renal impairment (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73m2), albuminuria (albumin/creatinine ratio ≥3 mg/mmol), and proximal renal tubular dysfunction (retinol-binding protein/creatinine ratio >2.93μg/mmol and/or fractional phosphate excretion >20% with plasma phosphate <0.8 mmol/L) in 596 HIV-infected and 544 HIV-uninfected AGEhIV Cohort Study participants. We also assessed whether being HIV-infected on cART, with follow-up censored when cART regimen was modified, was associated with greater eGFR decline or worsening albuminuria (increase ≥10%/year with change in albuminuria category). Results Human immunodeficiency virus infection was independently associated with renal impairment (adjusted odds ratio [aOR] = 2.1; 95% confidence interval [CI] = 1.0-4.4), albuminuria (aOR = 5.8; 95% CI = 3.7-9.0), and proximal renal tubular dysfunction (aOR = 7.0; 95% CI = 4.9-10.2]). Among 377 HIV-infected and 479 HIV-uninfected individuals (median follow-up = 3.9/4.1 years, respectively) included in longitudinal analyses, being HIV-infected and remaining on unmodified cART was independently associated with greater eGFR decline (-0.56; 95% CI = -0.87 to -0.24 mL/min/1.73m2/year) and worsening albuminuria (aOR = 2.3; 95% CI = 1.3-4.0). Conclusions In these middle-aged individuals, HIV infection was independently associated with renal impairment, albuminuria, and proximal renal tubular dysfunction. Human immunodeficiency virus-infected individuals on cART (predominantly containing tenofovir disoproxil fumarate) were also more likely to experience eGFR decline and worsening albuminuria compared with HIV-uninfected individuals.
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Affiliation(s)
- Katherine W Kooij
- Department of Global Health, Academic Medical Center, and Amsterdam Institute for Global Health and Development
| | - Liffert Vogt
- Department of Nephrology, Academic Medical Center
| | - Ferdinand W N M Wit
- Department of Global Health, Academic Medical Center, and Amsterdam Institute for Global Health and Development.,Division of Infectious Diseases and Center for Infection and Immunity Amsterdam, Academic Medical Center.,HIV Monitoring Foundation
| | - Marc van der Valk
- Division of Infectious Diseases and Center for Infection and Immunity Amsterdam, Academic Medical Center
| | - Rosan A van Zoest
- Department of Global Health, Academic Medical Center, and Amsterdam Institute for Global Health and Development
| | - Abraham Goorhuis
- Division of Infectious Diseases and Center for Infection and Immunity Amsterdam, Academic Medical Center
| | - Maria Prins
- Division of Infectious Diseases and Center for Infection and Immunity Amsterdam, Academic Medical Center.,Public Health Service Amsterdam, Infectious Diseases Research, Amsterdam, the Netherlands
| | - Frank A Post
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Peter Reiss
- Department of Global Health, Academic Medical Center, and Amsterdam Institute for Global Health and Development.,Division of Infectious Diseases and Center for Infection and Immunity Amsterdam, Academic Medical Center.,HIV Monitoring Foundation
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49
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Fong G, Skoglund EW, Phe K, Guastadisegni J, Shea KM, McDaneld PM, Perez KK, Sofjan AK. Significant Publications on Infectious Diseases Pharmacotherapy in 2016. J Pharm Pract 2017; 31:469-480. [PMID: 28847232 DOI: 10.1177/0897190017727212] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE This is a summary of the most important articles on infectious diseases (ID) pharmacotherapy published in peer-reviewed literature in 2016 as selected by clinical pharmacists with ID expertise. SUMMARY The Houston Infectious Diseases Network (HIDN) was asked to identify articles published in peer-reviewed literature in 2016 that were believed to contribute significantly to ID pharmacotherapy, including human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). A list of 46 articles on general ID pharmacotherapy and 8 articles on HIV/AIDS were nominated. Members of the Society of Infectious Diseases Pharmacists (SIDP) were surveyed to select 10 general ID articles believed to have made a significant impact on general ID pharmacotherapy and 1 article most significant to HIV/AIDS pharmacotherapy. Of 445 SIDP members surveyed, 212 (47.6%) and 95 (21.3%) members voted for general ID pharmacotherapy- and HIV/AIDS-related articles, respectively. The 11 highest-ranked papers (10 general ID-related articles and 1 HIV/AIDS-related article) are summarized here. CONCLUSION With the large number of ID-related articles published each year, it can be challenging to stay current with the most relevant ID publications. This review of significant publications in 2016 may provide a starting point for that process.
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Affiliation(s)
- Gary Fong
- 1 Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Erik W Skoglund
- 2 Department of Pharmacy, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, TX, USA
| | - Kady Phe
- 2 Department of Pharmacy, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, TX, USA
| | - Jessica Guastadisegni
- 3 Department of Pharmacy, Michael E. Debakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Katherine M Shea
- 4 Infectious Diseases, Innovative Delivery Solutions Cardinal Health, Houston, TX, USA
| | - Patrick M McDaneld
- 5 Infectious Diseases, Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Katherine K Perez
- 6 Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA.,7 Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA.,8 Center for Outcomes Research, Houston Methodist Research Institute, Houston, TX, USA
| | - Amelia K Sofjan
- 1 Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
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50
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Mugwanya KK, John-Stewart G, Baeten J. Safety of oral tenofovir disoproxil fumarate-based HIV pre-exposure prophylaxis use in lactating HIV-uninfected women. Expert Opin Drug Saf 2017; 16:867-871. [PMID: 28571500 PMCID: PMC5581312 DOI: 10.1080/14740338.2017.1338271] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 05/31/2017] [Indexed: 12/20/2022]
Abstract
INTRODUCTION In settings where HIV is prevalent in heterosexual populations, pregnancy and postpartum breastfeeding periods can be associated with substantial HIV acquisition risk. Pre-exposure prophylaxis (PrEP) with daily oral tenofovir disoproxil fumarate (TDF)/emtricitabine is an attractive HIV prevention option for women who are lactating but data are limited on its safety during the lactation period. Areas covered: We provide a concise synthesis and summary of current evidence on the safety of TDF-based PrEP during breastfeeding. We conducted a review, searching Pubmed database and major PrEP conferences for primary studies with TDF-based PrEP exposure during postpartum breastfeeding. Expert opinion: TDF-based oral PrEP is an effective female-controlled HIV prevention option. There is evidence supporting the safety of TDF use for infant outcomes during breastfeeding in antiretroviral treatment regimens for HIV and hepatitis B virus, and more limited, but consistently safe, data from use of TDF as PrEP. The potential for risk is arguably outweighed for at-risk individuals by HIV prevention benefits, including indirect protection to the infant as a result of preventing HIV in the breastfeeding mother. As PrEP delivery is scaled up in heterosexual populations in high HIV prevalence settings and for at-risk persons in other settings, implementation science studies can provide a framework to increase the accrual of safety, acceptability, and use data related to PrEP during lactation.
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Affiliation(s)
- Kenneth K. Mugwanya
- Department of Global Health, University of Washington, Seattle, USA
- Division of Disease Control, Makerere University, Kampala Uganda
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Pediatrics, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Jared Baeten
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
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