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Updates in HIV PEP Protocols and Guidelines

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Recent updates to U.S. guidelines for HIV post‑exposure prophylaxis (PEP) provide modernized recommendations for both non‑occupational and occupational exposures — reflecting advances in antiretroviral therapy and evolving evidence. This course summarizes key changes, including preferred regimens, testing/follow‑up modifications, and special‑population considerations, and explores how these updates influence clinical practice. You will gain the practical knowledge needed to inform prompt PEP decision‑making, patient counseling, and care coordination.

HOST
Rachel Maynard, PharmD
GameChangers Podcast Host and Clinical Editor, CEimpact
Lead Editor, Pyrls

GUEST
Kenric Ware, Pharm D
Clinical Associate Professor of Pharmacy Practice
Mercer University

 
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CPE INFORMATION
 Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Identify current guideline recommendations for initiating HIV PEP after occupational and non-occupational exposure.
2. Describe key considerations for selecting and managing HIV PEP regimens.

Rachel Maynard and Kenric Ware have no relevant financial relationships with ineligible companies to disclose.

0.05 CEU/0.5 Hr
UAN: 0107-0000-26-052-H01-P
Initial release date: 2/16/2026
Expiration date: 2/16/2027
Additional CPE details can be found here.

SPEAKER_00:

Hi, HealthMart Pharmacists. From your education partner, CE Impact, this is Game Changers. I'm your host, Jen Moulton, and each week we have a conversation on a hot clinical topic that will keep you current in practice and position you as a resource for prescribers and patients. Thanks for listening in.

SPEAKER_01:

I'm your host, Rachel Maynard, and today we'll be talking about a topic where pharmacists can play a critical role. So this is the second part of our two-part series on HIV prevention. Last week we talked about HIV pre-exposure prophylaxis or PREP. Now this week we'll look at post-exposure prophylaxis or PEP. And specifically, as the name describes, PEP is used to prevent HIV after a potential exposure. And this is a very timely topic because in the last year we saw two new sets of guidelines published for post-exposure prophylaxis. One was for post-exposure prophylaxis after sexual injection drug use or other non-occupational exposure to HIV. The other is for the management of occupational exposures to HIV and recommendations for post-exposure prophylaxis in healthcare settings. So two very different populations and considerations, but luckily we'll see that there are a number of similarities between some of these recommendations. And these guidelines were a long time coming because the last set of occupational PEP or OPEP guidelines were published in 2013. The most recent non-occupational guidelines or NPEP guidelines were from 2016. And we know there's been a lot of new HIV medications approved since then, so it's a great time for us to look at the new guidance. And so our guest today, Dr. Kenrik Ware, is going to help lead us through some of these changes and updates and let us know the key takeaways. So welcome, Kenrick. We're so excited to have you.

SPEAKER_02:

Thank you for having me. I'm glad to be here.

SPEAKER_01:

Excellent. And Kenrik, for our listeners to learn a little bit about you, would you mind sharing a little bit about your background, your current role, and maybe why you're interested in this topic?

SPEAKER_02:

Absolutely. So again, thank you for having me. My name's Kenrik Ware. I'm a clinical associate professor of pharmacy practice here at Mercer University College of Pharmacy. I've been here a little over two years now, and prior to coming here, I was at a different pharmacy school for about 11 years. So I've been in academia roughly 12 or 13 years. I attended pharmacy school at Howard University College of Pharmacy in Washington, D.C. Then after that, I completed a postgraduate year one or PGY1 residency program, and then also a second year as well, where I was able to earn my Master's Business Administration or MBA. And then I went on to practice in HIV care, initially in Columbia, South Carolina. So I spent about a decade or so there practicing at statewide level with HIV, but focused more in Columbia. I earned my American Academy of HIV Pharmacist Credential or AA HIVP. I'm really active with the American Academy of HIV Medicine in their item writing assessments. I'm one of the people who assembled to help write some of the items for the credentialing examination. I'm also pretty heavily involved in a public policy committee with the American Academy of HIV Medicine. And recently, as of late last year, I was selected to be the chairperson for the American Academy of HIV Medicine, the Georgia board position. So the board of directors are unfortunate represent our great state of Georgia. So I'm really excited about that. So that's a little bit about me and my role. And again, I'm excited to talk through this with you today.

SPEAKER_01:

Excellent. Well, I am very impressed by your expertise. I'm sure you're going to have a lot of really excellent examples and recommendations for us to take away. So really excited to hear your insights on this really important topic. So let's just start by getting everybody on the same page and talking about an overview of, again, we're focusing on post-exposure prophylaxis today. So can you just give us an overview of what post-exposure prophylaxis or PEP is and just sort of setting that framework for us?

SPEAKER_02:

Sure, absolutely. So so thank you. So as the name implies, we're talking after. So post or after, we're after an exposure or a suspected exposure to HIV. So we have different routes when we say non-occupational or NPEP for short, and occupational, which is OPEP for short. So non-occupational, we typically think of unfortunately along the lines of sexual assault. So it's in those in those cases would be more of a non-occupational exposure to HIV. Occupational, what we traditionally think of there is more of a needle stick injury within a healthcare system. And so we'll talk about, you know, thankfully, the guidance around uh NPEP and OPEP are pretty consistent from a management perspective. But when we think about post-exposure, again, we're thinking after after a known or suspected. So just to make sure we keep that in mind, maybe a suspected or highly likely exposure to HIV, we would want to implement post-exposure prophylaxis.

SPEAKER_01:

Okay, and that's a great summary. And I think one of the really important points is the timing of this post-exposure prophylaxis and when it needs to be initiated. So maybe you can just speak to that quickly.

SPEAKER_02:

Absolutely. Yeah. So you're exactly right. The timing is paramount. I mean, we're we're really looking within 72 hours. So that's our that's our line in the sand where we want to implement post-exposure prophylaxis. And the duration is important, right? So we're really thinking about 28 days. So roughly four weeks, 28 days. So within 72 hours and for 28 days. So those are our two markers that we really need to meet to have the best chance of success.

SPEAKER_01:

Great, great. Yeah, thank you for calling that out. And good, good way to sort of frame these numbers to keep in mind within 72 hours, and really the sooner the better, even within 24 hours, was even further emphasized in these most recent guidelines. So the sooner the better. And really, again, that sort of ties back to the role of pharmacists being in a position where they're often very accessible to patients and can help either refer or, in some states, initiate PEP to really get a patient started ASAP in terms of that timing. And then also the 28 days, as you mentioned. So it is different than PrEP, which we talked about last week, where that's you know pre-exposure prophylaxis and you're taking it to prevent possible acquisition. But this is post-exposure prophylaxis. You've had a possible exposure, and you're just having this 28-day timeframe to prevent acquiring HIV after that potential exposure. Would you say that's a fair summary?

SPEAKER_02:

Absolutely. Yeah, very much so. And I think that that's the key point is that 28 days is really, as pharmacists, really helping people to be as inherent as possible. Right. A lot of education on the front end to make sure this isn't one of those cases where we want people to, we never want people to miss doses, but definitely not now. We want to make sure that they're as consistent as possible. It the data really doesn't support a lot of forgiveness around missing doses. And so it's really important that we emphasize that the 28 days really needs to be consecutive, not two tomorrow, none today, right? We need to be as consistent as we can. And I think pharmacists have a really big role in that because obviously there is some built-in forgiveness in other conditions when people are being managed for a longer period of time. We we're all human, people may miss a dose. You know, we can empathize with that. But in this case, we really want to be as as adamant as possible that people take it every single day.

SPEAKER_01:

Thank you so much for emphasizing that because that is challenging for all of us, right? To to adherence is a challenge. And just highlighting the importance of this situation and again pharmacists' role in doing that, but also the fact that it is just 28 days. So hopefully that strict adherence may be more manageable because it's a limited time frame that we have to be thinking about.

SPEAKER_02:

Absolutely. And I think that's a good point, also, where we can assure patients, you know, quite the data is pretty clear that quite a bit of the side effects or the intolerability is really for a longer period of time. So it's not that people won't experience anything at all, but really the data is pretty clear on a lot of the complications or some of the adverse concerns with the medication for people who are on chronic management for an extremely long period of time or indefinitely, you can you can make the case. And so I think for four weeks, looking at it through through that perspective, we can really encourage patients that if you push through, you really shouldn't see some of this, some of the your intolerability that other people were experiencing over longer periods of time.

SPEAKER_01:

Right, right. Great point to call out there. So we got a little bit off track there, but that that's a great, real, you know, concise way to be thinking about patients and and who who might be what are the key considerations in terms of timing and duration. But let's talk about which patients are going to be potential candidates for this because that's another important consideration. And you mentioned the needle stick, you mentioned sexual exposure as possibilities, but talk a little bit more about what types of exposures are a concern and where you might be needing to think about PEP and starting PEP.

SPEAKER_02:

Sure, I think one of the main exposures we kind of think of when we when we break it down by category, particularly receptive anal sex, right? So if someone is a participant of receptive anal sex, the the exposure is pretty clear. We start thinking about who can benefit from it the most. And particularly if it's an unknown exposure, as as Pep would would imply. So I think we're thinking more rectal sexual activity, as you alluded to, you know, we're thinking non-occupational, maybe more sharing of injection drug use equipment. And think on the lower end of that would be penile vaginal sex. So we're looking at, you know, classifications, the data's pretty clear about particularly people who, again, participate in anal receptive sex are at a higher likelihood of encountering HIV. And so that would be really that category when we're looking at sexual histories, we're looking at past medical histories, that's really important to keep in mind.

SPEAKER_01:

Okay, excellent. And in terms of either non-occupational or occupational, how important is it to know the sources, the sources' status, whether or not they have HRV or not, and whether that dictates whether PEP is is to be recommended or not? Because just looking in the guidelines, I know there's a lot of sort of case-by-case scenarios that may need to have some additional decision making made. But in terms of a patient who was exposed to somebody with known HIV versus if the source is unknown, can you talk through some of that decision-making process a little bit?

SPEAKER_02:

Yes, absolutely. I think the, well, the HIV source, again, if it's known, is it's really a fork in the road. The guidelines really are pretty clear about whether it's undetectable versus detectable. And I'll kind of unpack that a little bit. When we think about an undetectable viral load, uh, really we're we're talking about the HIV is so low in the body that effectively there's no risk of transmitting it to someone else. So the person isn't cured from HIV, but they have that very low, again, what we consider undetectable, which you may hear the mantra in the HIV space of undetectable equals untransmittable, right? And that's where that really comes from. That's important because the guidelines, with this update, it's pretty clear about the shared decision making. If a person encounters someone with an undetectable viral load status, it's a shared decision making around with the provider and the patient who encountered that person, whether or not they want to initiate PEP. And so that's a huge development from the previous versions of the guidelines because again, now we're we're we're making that decision in tandem or as a team to make sure people understand that the data based upon that U equals U on the television untransmittable data, that may be an opportunity for people to forego taking PEP. Now, obviously, if it's detectable, we recognize that people have higher buyer loads. We definitely want to get them started. And I do want to point out here that we don't want to wait for, we the guidelines don't recommend waiting to initiate PEP to determine the status of HIV. We really want to make sure we get started as soon as possible. But it is important for the audience to know that it it depends on the HIV that you could say categorization of undetectable versus none. And the guidelines are pretty clear because of so much data we have around undetectable equals untransmittable, there needs to be more shared decision making there.

SPEAKER_01:

Excellent summary there. And really important to call out that that you equals you concept, because that I do think it is a pretty big change from the prior guidelines where that wasn't, I don't think, it even really addressed in the prior guidelines. Um, and also to to to sort of think about exposure risk, people what about people taking PrEP themselves and being exposed? So if they're taking HIV pre-exposure prophylaxis routinely for their own risk reduction, and they are exposed to somebody with known HIV, that is also something addressed in the the guidelines now because it's you know a different sort of scenario also because they are also already taking PrEP. And so maybe you could talk about that a little bit and what the decision making there is.

SPEAKER_02:

Yeah, absolutely. So that's a really good point. And you're right, that's another development that wasn't necessarily prominent in the previous guidelines. I think there is it's really an honest conversation with with the patient taking PrEP, like how consistent they've been, you know, how inherent they've been to that PrEP regimen. Because I think if they have been pretty consistent, haven't really missed any doses, you know, you probably could forego PEP in that in that moment as well. But I think some patients will probably be honest, particularly if they're on the oral options. As our audience may know, now we have injectable options for PrEP. So that's a bit different because we've obviously watched all of that go in. But if someone is actually taking oral options, they may be honest and say that they've missed a few doses here or there. I think that's a different consideration around PEP if the adherence hasn't been as optimal. Again, if we're thinking uh intramuscular injection or subcutaneous as we have now for PrEP, then that's that's vastly different because we know all of it was in. But orally, I think that's an individualized conversation to get as you know honest information as possible to say, hey, we really want to see if you can benefit from post-exposure prophylaxis based upon your own admittance of how you've been taking PrEP.

SPEAKER_01:

Yeah, excellent summary. And just another interesting sort of facet of that it's not necessarily all exposures equal starting PEP. There's a lot of nuance in there to consider sometimes. But, you know, in terms of people who would not necessarily be candidates for PEP, could you run through some examples? So, you know, the it's it depends on the type of exposure in terms of what bodily fluids the person's exposed to, or and there are there's certain ones where you can rule out any potential concern of transmission. Um and I think going back to the idea of you know, people who were exposed more than 72 hours ago, they would be ruled out. But maybe you can speak about that a little bit. Are there patients who you're not so concerned about starting PEP outside of potentially the ones on PrEP and adherent to the injectables? That might be one consideration, but any others that come to mind?

SPEAKER_02:

Sure, though, great question. I think people who look you're exposed to maybe saliva or urine or feces, you know, tears, some of those secretions really is really no risk there. I mean, we really shouldn't, you know, initiate PEP in those individuals. So I think some of those sweat, you know, obviously we're thinking about HIV and you recognize the sensitivity towards that in the community is different from different people, right, based upon their level of knowledge. So we can understand why someone who maybe shook someone's hand who was sweaty maybe have some concerns around it. But I say all of those things where we're thinking again, sweat, tears, saliva, urine, you know, feces interaction, all of those things we definitely wouldn't want to initiate PEP, but that is an education point because you recognize everyone has a different level of knowledge about this.

SPEAKER_01:

Absolutely. So there you described well those key considerations where you'd be thinking about starting PEP. We talked about the cases where you might not need to start PEP, but there are those case-by-case considerations. And you and I were chatting a little bit before the podcast about the National Clinician Consultation Center and CCC. And I just want to call out that they have a PEP hotline that can help walk through some of those case-by-case scenarios because it's not always black and white, and you sometimes do need some of that expert consultation. And I just wanted to call that out as a resource because it just seems like an underutilized available tool for any pharmacist who might be helping a patient decide whether to initiate PEP. Have you had any experience with that yourself or any insight on that?

SPEAKER_02:

Well, I haven't personally had experience with it, but I know others who have used it. And it's been really helpful because as we stated at the outset, you're up against the clock, right? So we you need responsive information. And from everything that I've heard, people are really available, the information is really accessible, right? So it's not a delay in getting in touch with people. I think sometimes that's a concern. I will say, admittedly, as a practicing pharmacist or whoever is a healthcare provider, you're wondering we'll only have 72 hours. Maybe I won't be able to get in touch with someone, or I'm going to be on hold for X amount of time and have other responsibilities. So I think just kind of settling that, that it is very accessible because they recognize too, right, that it's a it's a it's a time crunch. So that's something I will say is that from all accounts that I've heard, the responsiveness is excellent, which you would expect it to be if we need to get someone started within 72 hours. And as you stated, the earlier the better, you know, within 24 hours ideally. So we definitely don't want to be held up, you know, in processes like this if we don't have to be.

SPEAKER_01:

Absolutely. And so thinking about, you know, the the the idea of the earlier the better and getting people started, you know, there's just I think it's just really important for pharmacists to feel empowered with going back to the point you mentioned about starting and not waiting even for any baseline assessment, or if in doubt, or trying to get not trying, you know, not waiting for trying to identify the source's HIV status, but if in doubt, start PEP and you know, we can reevaluate later. Is that a fair assessment? Would you say err on the side of starting if if you have suspicion and there's enough risk warranted to to initiate start the sooner the better? And then, you know, if testing comes back and and you need to reevaluate, do that, or how would you is that a fair thought process?

SPEAKER_02:

It is, it's very fair. I think you know that you you can always course correct, so to speak, later on, you know, if you need to do that, but yeah, I think you should initiate as soon as possible. We know that the evidence is pretty clear, the sooner the better, right? And so I think just the the deliberation time in this case, right, isn't there. Like we just don't have that level of forgiveness. So I think the sooner we can get started, the better.

SPEAKER_01:

Okay, great. So let's talk about what PEP regimens look like. We've been talking about what it is and who to be thinking about it in, but let's get into the nitty-gritty and what are the regimens that are recommended for either NPEPER, PEP, or both. I'll let you speak to that.

SPEAKER_02:

Sure, yeah. Well, that the guidelines again are pretty clear here when we think about our class of medications that are really at the forefront here are integrated inhibitors. Right. So we think of, when we think of integrace inhibitors, how I like to remember them, things that end in gravir, right? So here we're thinking bic tegavir would be one of our uh our features, and then Dolutegra. So the guidelines really speak to bictegra coupled with what we call nucleoside reverse transcriptase inhibitors or NRTIs. And two of the more prominent ones would be your tenophivir distoproxal fumarate or TDF for short. You also have tenophivir allophenamide or TAF. They're really, I kind of like to think of them two sides of the same coin, so to speak. They have some advantages and some some limitations to each of them, but you want to give that width what we call intracidabine, another NRTI. So they're they're usually co-formulated, so they will come together, the tenophovir and the intracidabine, whatever version of tenophovir you're you're using, and you couple that with big tergavir. So you have two NRTIs and an integrated inhibitor. And then when we look at dolutergavir again, another integrates inhibitor, so remember gravir. So another integrated inhibitor, you would do dolutergavir with tenophavir and intracidivine. Now the difference here, which is I think is the key difference, is when we think of the big tergavir arm, particularly with TAF or tenulfavir, elephenamide, and infracidabine, that's a single tablet regimen. So that's important, you know, we think from an adherence perspective. Now, if we look at dolutegavir plus the tenulfavir and intracidabine, those are going to be two separate tablets. So that thing's something the guidelines are pretty clear about the value of that single tablet regimen being able to be initiated as soon as possible. But efficacy-wise, it really bears out they both are fairly equally effective, but that single tablet regimen does make a difference. And we've gleaned a lot of that from just long-term management of HIV, right? That data really kind of trickling back here into this post-usposer prophylaxis space.

SPEAKER_01:

Excellent. So those regimens that you mentioned are also HIV treatment regimens as well, then. That's right.

SPEAKER_02:

They are.

SPEAKER_01:

Okay, excellent. And I think you made a really important point. So you called out sort of the two options in that preferred pathway, calling out the two different integrase inhibitors being, you know, Dolly Tigre and Big Tiger Verear, but the key difference with big tiger veer being that it comes in combination with the two NRTIs as a single pill. And from an adherence perspective, that could be an important consideration, especially for just this 28-day course.

SPEAKER_02:

Yeah, absolutely. And I think it's easier for really, I would say any of us to probably adhere for 28 days to one tablet than as opposed to two, right? So I think that's something that we try to get across two patients so they can, again, to keep them on track with that 28 day adherence.

SPEAKER_01:

Are there any other considerations to be thinking about besides Pill Burden in terms of those two sort of preferred pathways? And again, those preferred, those preferred regimens that you talked through are for both OPEP or NPEP. So, regardless of exposure, the regimen is the same. And that Is a great thing because that makes it easier for us to recommend. And I know the guidelines when they were in development, there was a uh an effort to harmonize those recommendations. So that's what we've seen borne out. But in terms of those two integrate-based inhibitors, sorry, integrace inhibitor-based regimens, any other considerations or differences besides the pill burden that you'd be thinking about when evaluating for a patient?

SPEAKER_02:

No, I I think you know the the TAF component, the the only other consideration is here, obviously the single tablet regimen with big tegavir only includes the TAF component. And so if we're thinking TDF, the the older formulation tenophravir, then we, you know, obviously that would be more of a diagravir piece. I bring that up because in the from a assets to care perspective, we think about the generic availability of these products. The Tinophravir dieselprostor fumarator TDF is available generically. So if we're looking at, again, even though we don't want it to be a driver of our decisions, it's just truly the best medication or the one that people can afford, right? And so if we are utilizing a generic option, then a single tablet regimen wouldn't be, wouldn't be what we go to, right? We would need to defer to or go to the dodgy serg-based regimen with to nofavir disoproxal fumurate, TDF, and infracidamine. So I think that's the biggest difference there is if we're thinking the generic availability, that really wouldn't apply to that single tablet regimen.

SPEAKER_01:

Gotcha. Okay, that's a really important consideration. Again, thinking about the time frame, we're working on a time crunch. And if payer restrictions are going to be a consideration, that could be something that weighs in that decision, definitely.

SPEAKER_02:

Absolutely. And even just availability, right? So we're thinking at the pharmacy level, right? You know, we what you know, what product do we have available within that 72-hour window? Practicing, I didn't mention this at the outset, but I do also practice in a community pharmacy from time to time. And just ordering a medication, it's just not reliable enough to get it within that 72 hours. So you're really working on what you have on hand. And, you know, by and large, you may have more readily more readily access to that, to that generic availability on shelf, on on hand. So that may be a big driver of the decision. If you have that in stock and you don't have to order already up against that 72-hour window, I would definitely not advise that. I mean, it's so many things to go wrong there. And so you want to utilize what you have.

SPEAKER_01:

Yeah. Okay, excellent summary. And boy, you rattled off those drug names in the regimen so well. So thank you for that great summary. In terms of any other notable updates from the guidelines, is there anything else you want to call out that our listeners should be familiar with outside of those updates to the regimens themselves, which are really important and a big change from prior guidelines? But any other key updates that we should be aware of?

SPEAKER_02:

No, we talked, we talked more about the we talked about the U equals UP, so that's the big one. And I think that maybe the other thing is you you'll hear like drug interaction potential with multivitamins, perhaps with INAG race inhibitors. Right. So a lot of our patients are on multivitamins. And so the goal there is to really try to separate that administration out, you know, as far as possible from each other. I mean, different recommendations will offer different timelines. How I like to advise people, particularly if they're on a single tablet regimen, you know, if they're taking it once a day, you know, kind of take it as far apart as you can from your multivitamin. The nature of that is that we have evidence to show that some of our what we call polyvalent cations, so that's a fancy way of saying kind of our calcium and our iron and magnesium and aluminum, those things can bind to our integrates inhibitors and decrease their effectiveness. Now they do that to varying degrees and in very to to in various people, but that is a caution that we should be, you know, checking for is are people taking a multivitamin? Are they taking some type of impacted? And we want to make sure that if they are, it's not necessarily they need to stop it. I mean, we can assess that. Well, can they can they stop for 28 days to make sure that we're clear of it? And if a person cannot stop, then we want to make sure we're administering those as far as possible from each other.

SPEAKER_01:

Right. Excellent point. So again, with this integrace inhibitor-based recommendation, that is a very important consideration. The fact of the interaction with polydeneth, as you said, antacids, proton pump inhibitors too. Is that another one with the integrace inhibitors?

SPEAKER_02:

Not as much there, not as much the proton pump inhibitors, because the acidity really isn't, you know, what's the concern when we think of drug interactions with proton pump inhibitors or H2 receptor antagonists, really, those amount to drugs that need more of an acidic environment to be absorbed because obviously those drugs are decreasing the acidity. So, no, not as much there as we see with the multivitamins.

SPEAKER_01:

Okay. So, but yeah, but great point to clarify that asking about OTC options that patients may be taking because they may not have reported those to the pharmacy, even if they're picking up these medication, the HIV PEP regimens at the pharmacy, we may not know that they're taking an over-the-counter vitamin and or an antacid. And that's a really important point to be aware of and just asking about so that we can help avoid any potential interaction. Because again, we want patients to be getting the most efficacy as possible from this regimen. And so that's a really good call out with this with these new options.

SPEAKER_02:

And I really just echo that one other point I would mention is that sometimes they are not on it at the outset, but you know, 28 days is a long time. So they may be day 13 or day 14, and they want to start a multivitamin. And so I think having that conversation, even if they're not on it, I think sometimes that's an important distinction to make is sometimes we overlook the conversation if they don't report being on it. But I think it's important to say, well, look, this 28 days is effectively a month that we're going to ask you to take this every single day. These are some things you want to be thinking about. And if you just don't need your multivitamin, this isn't a good time to just pick up one and try it, right? You want to you if you want to try something, let's not do it during this 28-day.

SPEAKER_01:

Yeah. Excellent point. So I think that transitions really well into other counseling points to be aware of when patients are initiating PEP. And so the interactions is an important consideration. We've talked about adherence a few times as well and really emphasizing that strict adherence with this regimen. Any other key counseling points? You you also alluded to side effects and the fact that this is a shorter course, so it's not something we're necessarily as concerned about, these long-term potential effects in terms of general tolerability and advice on management. Any thoughts there that you'd want patients to know about?

SPEAKER_02:

Yeah, no, I think counseling points. Yeah, I think the biggest thing is just you know taking it every day, you know, not doubling, you know, make sure that people, you know, that is, you know, we don't have the forgiveness here that we would have and other considerations. But yeah, tolerability-wise, I think, you know, by and large, for that 28-day period, you know, people should be fine. The counseling point is if people are experiencing some type of diarrhea or some other GI upset, is that they discuss that with their pharmacist and then maybe take something to remedy that in that period of time. So I think, again, we have to make it through that 28 days. We want people to be as comfortable as possible. But I've counseled on that quite a bit is before you you stop, you know, let us help you to manage this. We recognize that none of us will raise our hand to get diarrhea or any other type of adverse concern. But we want to make sure that we do have things that can help you through this 28-day period, which I think is sometimes patients don't think of because they think, oh, I can stop this and get on something else, or I can try something else. And if we can make it through that 28-day period, it's just a lot easier than trying to reinitiate for something else when you probably have similar concerns with another regimen as well during that time period. So I think that would be the counseling point I would would make is let's do what we can to get through this 28 days as consistently as we can.

SPEAKER_01:

Absolutely. And and also, you know, as you called out before, that these are generally pretty well tolerated anyway. So they shouldn't expect to have a lot of notable side effects, nausea, diarrhea, headache, those kind of tiredness, maybe, but to, as you say, proactively let patients know about potential side effects and also really encourage them to speak to you if they are having any side effects or talk about how to manage those proactively so that a patient doesn't just stop it and then you know, as you say, there's challenges with that. The other thing, you know, that comes to mind is that if they are having unprotected sex, for example, and they're taking this regimen, continuing to do those safer sex practices because you know they may be at risk. Again, that's why they're taking the post-exposure prophylaxis to reduce their risk. So safer sex practices reinforcing that. How about HIV testing, both pre and post-testing? Because I think that's important. We haven't really touched on that. If you could speak to that a little bit.

SPEAKER_02:

Yeah, absolutely. I think we obviously, like you said, the pre-testing is important, but again, as we stated at the outset, it really shouldn't delay our initiation. It the guidelines really call for about four to six weeks after that point, is to retest. Right again, we're we're looking to make sure the person has not sero converted or what we consider, I guess, a fancier way of going from not having HIV to having HIV. And then the the ultimate is that 12-week mark. So the guidelines are pretty clear in both the NPEP and the OPEP is that at 12 weeks, that's really what we want to test to ensure that a person is still not living with HIV or they're HIV negative, right? At that point in time, we would have had enough time for the drug to make its way out of the body, and we really have a good picture of the HIV status. So I think that obviously baseline, the guidelines will recommend four to six weeks for most people there, and definitely that 12-week mark is where we want to do kind of our our our ultimate consideration of whether or not HIV is in the person's body or not.

SPEAKER_01:

Excellent summary. So thank you for calling that out and a reminder that it is a short course, but there may be some follow-up that needs to happen afterwards, even a few months later.

SPEAKER_02:

So and I think that's important too. I'm glad you mentioned that because that's another part of that initial counseling that I like to do when I'm talking to people about this. Is it it is 28 days, but then we do have other things that we're so if we're thinking transportation barriers, if we're thinking other things, I think pharmacists are having a huge role in some of these things we consider our social determinants of health, thinking through that. Like how do we ensure that you're able to get back and have this testing done? So, yes, it's a heroic feat to get through that 28 days, particularly if you're having some discomfort, but we still have to continue to test you because we want to make sure that the drugs uh did what they were supposed to do. And I think if we can foresee again transportation concerns, other things that we can work through at the outset, I think patients are better for it. You know, they really appreciate that more proactively as opposed to at the end, we didn't assess transportation concerns. I keep bringing that up because that's a huge one, particularly in some of our rural areas. We didn't assess that at the outset. So now we're scrambling to figure out how do we get a person back in for testing, because we have to, we have to absolutely have to have that testing done. So I think thinking of that at the on the front end is very important.

SPEAKER_01:

Yeah, I'm glad you called that out. And again, sort of having those proactive conversations with patients, even at the initiation of PEP. And the other thing that I saw emphasized in the guidelines is the fact that uh a follow-up, a check-in within a couple of days of initiating. So even, you know, one to three days if you can, because I know that none of us have extra time or like are looking to add more to our workload. But as you say, this is such a critical scenario where that adherence is so important. So checking in early on in therapy, too, I think is something that pharmacists can play a big role in. And then, you know, I think the other thing too that you've brought up a lot of fantastic examples of pharmacists' opportunities to improve access to PEP. I think one that comes to my mind too is about people who may have or be at risk of repeat exposure and having that conversation about PrEP in those cases. So, or even this PEP to prep concept where people go through their course of PEP and then can transition right to PrEP if they're at ongoing risk. Anything to say about that concept or to share there?

SPEAKER_02:

Yeah, absolutely. I think again, another you know, proactive consideration, particularly if we're we're we're thinking after these 28 days, then what? Because that's usually the question right that we that anyone would have. Like after I finish this, now what? So the testing component as you alluded to, and then also that's a great opportunity to talk about prep, the options that are available for prep. And I would advance that even further, like what's available in your local, in your local context? Like, so what formulations of prep do we have available, right? And I heard you mention at the outset that that's been discussed previously as well, but that's very important because if a patient is makes it through that 28 days, as we hope they do, we want to have a good idea of what prep regimen they want to start. So, yes, we introduced the concept for prep, but now we're fortunate to have options available for prep. So it's not just one consideration or one formulation that people can use. Because I think having that conversation at the beginning, like, hey, this is how we expect it to play out. This is the post-testing that we're gonna ask you to do. And also, have you heard of prep? And if so, or if you have it, this is what it is. And these are the options that are available here to you in your local, in your local context. So that way I think you ensure that full continuity from PEP to prep, not just the concept of PrEP, but tangibly, this is what you can start taking once we once we round out your your PEP regimen.

SPEAKER_01:

Yeah, thank you so much for for calling that out. And I just love how this recurrent theme of this proactive discussion with patients keeps coming up because it is such a prime opportunity to be thinking ahead about what we can do to limit any potential barriers, the role of pharmacists in initiating PEP ASAP and our role, you know, in a in the community there to initiate. And and as we said, a number of states have allowed, have passed laws allowing pharmacists to initiate PEP independently. So just a lot of opportunity, I think, for pharmacists to be identifying and helping care for these patients. We are almost out of time, but I do want to just circle back on a couple of additional resources that we wanted to talk about. So we did already discuss the NCCC, that PEP line, and it's really easy to find. If you just Google it, it'll come up and you can find that hotline as a another source if you're looking for some expert guidance. As part of our, I will say CE Impact has partnered with Pearls, which is a modern next generation drug information resource and mobile app. And I also work with Pearls, and so Pearls provides some practical evidence-based tools and resources that tie in really nicely with CE Impact's passion for pharmacy education. And I just want to quickly show one of those examples again. This is meant to be a practical tool that pharmacists can use to help guide through that patient care process if you're managing a patient with PEP, HIV PEP. And so for those of you watching the video, I'm showing it on the screen right now. But for those listening, this is just a concise one-page document that reviews eligibility considerations. It has a side-by-side comparison walking through that care process for OPEP and NPEP, including those recommendations in terms of regimens that you walked through so nicely, Kenrick. So keeping those straight, I think is really helpful here. Just a nice quick, easy read and one pager. So just an example of a resource that is available from Pearls to help you care for patients. We will provide links to this resource in the show notes for the podcast and on the CE Impact website. So you have those on hand just in case you're interested in those. Now, to wrap up our discussion, this is our Game Changers Clinical Update podcast. So, Kenrik, what is the game changer you'd like our listeners to walk away with today?

SPEAKER_02:

Yeah, I think that the game changer is that we we have regimens that are a lot more tolerable for people, right? We have this the single tablet regimen in most cases will be would be preferred and that people can take for 28 days to really try to overcome some of the that the adverse adverse concerns that they may have with older regimens. Again, I do also want people to recognize that the the older regimens that are not in the preferred guidelines anymore that not necessarily lack the efficacy, right? Because that's a question that comes up, right? It's not that we found out that these were better from an effectiveness perspective, just from a convenience, things that we know that impact adherence. So I do want to make sure we're all clear there that this hasn't been really an evolution in effectiveness, right? The the previous uh integrates-based regimen that was used was effective as well. It's just from a convenience, from an adherence perspective, a pill burden perspective, we've just come a long way. And so this is a better option. And the last thing I was just kind of looking ahead, there's some res some research out, or people are actively investigating. Maybe it's an opportunity to decrease that time frame that people are taking PEP from 28 days to a little bit shorter, maybe two drug regimens. So we talked extensively with our three drug regimen options here for PEP, but there are two drug regimens that are available to treat HIV that are very effective. And so the thought is maybe they could be effective in PEP. So again, these are future considerations. They're not they're not here right now, but these are things that people can consider. And one last thing is maybe an injection, you know, that people can take for post-exposure. You know, in the HIV treatment world, we have injections available that people can take over the course of months, right, to treat HIV. And so and to prevent HIV as well. So maybe the thought here is, you know, that may be game-changing for people, particularly if they have been a victim of some type of sexual assault or some type of trauma, and taking a pill every day is that daily reminder of that trauma, right? And so that's something that I think the guidelines don't necessarily speak to directly, but in in my own practice, I have had people to say, well, I don't want to be reminded of this 28 days. And so I think if we can evolve to the place where someone takes an injection one time and that protects them through that 28-day period, they don't have that constant reminder of that very unfortunate point in their life.

SPEAKER_01:

Well, Kenrik, you just summarized so many important points about the guidelines and key things for us to be aware of, practical recommendations, and also thinking about where we might be going. And you just summarized that also nicely. So thank you for your wealth of knowledge on this topic. It was just really great hearing from you, and I really appreciate you taking time out of your busy day to do this.

SPEAKER_02:

No, thank you for having me. I I enjoyed this area, as you can probably tell from me, my discussions of it. I've been really the bulk of my professional career in this space, and I'm just getting more and more excited about it. So, so thank you for having me, and it's been really good to be here today.

SPEAKER_01:

Excellent. And hopefully, when we get a recommendation for an injectable for PEP in the future, we'll have you back on.

SPEAKER_02:

Well, good. I would love to be here. So that's an affirmative for the future. So thank you for that.

SPEAKER_00:

Excellent. Thank you so much. And that's it for this week. Be sure to log in to Healthmart University to claim your CE credit for this episode. As always, have a great week and keep learning. We'll talk to you next week.