HIV Prevention: A Guide to PrEP and PEP

Listen in as we explore the latest pharmacologic strategies for HIV prevention—before and after exposure. Our expert panel breaks down key considerations for PrEP and PEP, including indications, drug selection, dosing, and monitoring.

Special guest(s):

• Caitlin Prather, PharmD, BCACP, AAHIVP
  • Clinical Pharmacy Specialist, Ambulatory Care
  • Inova Health System
• Michael A. Deaney, PharmD, AAHIVP
  • Infectious Diseases Clinical Pharmacist
  • Children's Hospital Colorado

You’ll also hear practical advice from TRC’s Editorial Advisory Board member:

• Andrea Darby-Stewart, MD
  • Associate Director, Honor Health Family Medicine Residency Program
  • Clinical Professor of Family, Community & Occupational Medicine
  • The University of Arizona College of Medicine - Phoenix

For the purposes of disclosure, Dr. Prather reports a relevant financial relationship [HIV PrEP] with Viiv Healthcare (speakers bureau).

The other speakers have nothing to disclose.  All relevant financial relationships have been mitigated.

This podcast is an excerpt from one of TRC’s monthly live CE webinars, the full webinar originally aired in June 2025.

TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter,or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

Claim Credit

The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Checklist: HIV Pre-Exposure Prophylaxis (PrEP)
• Checklist: HIV Postexposure Prophylaxis (PEP) Checklist

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Chapters

• 0:00 Introduction
• 1:52 CE Information
• 2:38 HIV Prevention: Historical Context & Definitions
• 4:07 PrEP and PEP Medications & Mechanisms
• 10:10 Effectiveness, Eligibility & Monitoring
• 17:17 Choosing Regimens: Patient Scenarios & Preferences
• 26:49 Dispensing, Counseling & Billing Considerations
• 35:43 Future Developments
• 37:01 Conclusion

Transcript

DISCLAIMER: 0:08

This transcript is automatically generated.

Caitlin Prather: 0:00

Honestly, anybody who's HIV negative and they're coming in and, you know, someone's requesting PrEP, it's usually fair. There may be something that they don't want to disclose to you, you know, something that they consider private or uncomfortable discussing. So as long as they're HIV negative and don't have any contraindications to therapy, then PrEP can be used in quite a

Michael A. Deaney: 0:28

Both PrEP and PEP regimens are extremely effective against HIV. Specifically with PrEP, they're very effective if you're using daily oral PrEP or injectable. About 99% for sexual exposures and 74% effective for those who inject drugs and have that exposure risk factor.

Narrator: 0:48

Welcome to Medication Talk, an official podcast of TRC Healthcare. Home of pharmacist's letter, prescriber insights, and the most trusted clinical resources. Proud to be celebrating 40 years of unbiased evidence and recommendations. On today's episode, we explore the latest pharmacologic strategies for HIV prevention, before and after exposure. Our expert panel breaks down key considerations for PrEP and PEP, including indications, drug selection, dosing, and monitoring. Our guests today include two pharmacists accredited by the American Academy of HIV Medicine. Dr. Caitlin Prather from the Innova Health System, and Dr. Michael A. Deeney from Children's Hospital Colorado. You'll also hear practical advice from TRC's Editorial Advisory Board member, Dr. Andrea Darby-Stewart from the University of Arizona College of Medicine, Phoenix. This podcast is an excerpt from one of TRC's monthly live CE webinars. Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers.

CE Narrator: 1:52

And now, the CE information.

Narrator: 1:58

This podcast offers continuing education credit for pharmacists, pharmacy technicians, physicians, and nurses. Please log in to your pharmacist's letter, pharmacy technician's letter, or prescriber insights account and look for the title of this podcast in the list of available CE courses. For the purposes of disclosure, Dr. Prather reports a relevant financial relationship by serving on Speaker's Bureau for HIV Prep with Veve Healthcare. The other speakers you'll hear have nothing to disclose. All relevant financial relationships have been mitigated. Now, let's join TRC editor, Dr. Stephen Small, and start our discussion.

Stephen Small: 2:35

This is a great topic for this month since it connects to our 40th anniversary. Our first pharmacist letter issue was released in June 1985 when the HIV epidemic was becoming a major concern for patients and healthcare providers in the U.S. and abroad. In that issue, we noted that there is no cure for AIDS on the immediate horizon despite all the news coverage. And we also pointed out that a team of researchers at the University of Colorado warned that switching needles by using the same syringe invites transmission of AIDS viruses. Now, although we still don't have a cure for HIV, we do now have meds that can prevent HIV, including exposure from things like injection drugs or needle sticks, which we'll talk about today. Before we dive into questions for our panelists, let's briefly define PrEP and PEP. PrEP, or pre-exposure prophylaxis, is intended to prevent infection before HIV exposure from things like sexual activity or injection drug use, and we've had med options for this since 2015. On the other hand, PEP, or post-exposure prophylaxis, is intended to prevent infection after exposure. This includes exposures from sexual activity, including cases involving assault, injection drug use, and also occupational exposures for healthcare workers, things like needle stick injuries. So keep in mind, PEP has been around longer than PrEP. It was introduced back in 1990. Now with that context, let's get into our questions. Caitlin, which medications can be used for PrEP and PEP? What are sort of the differences maybe there we can highlight?

Caitlin Prather: 4:16

So there are three medications that are currently FDA approved for use in PrEP or pre-exposure prophylaxis. The two oral options both contain emtricitabine as well as a version of tenofovir. So emtricitabine with tenofovir disaproxyl fumarate. This is the older version of tenofovir. It's often abbreviated as TDF. This is the generic of Truvada. And then emtricitabine with tenofovir alafenamide or TAF is Descovy. These are both taken as one tablet by mouth daily. And then our third option for PrEP is a long-acting injectable of cabotegravir. The brand name of this one is Apertude. And this one is administered intramuscularly as a lead-in phase of two doses given one month apart. And then after that, it is every two months. For PEP, we have a few different options for combinations. Essentially, in the preferred regimen, it's either a version of tenofovir and PrEP. either emtricitabine or lamivudine plus an insti, so either bictagravir or dolutagravir. So this regimen can be achieved by using either combining multiple combo products or as a single tablet regimen of something like bictarbi. So that's bictagravir, emtricitabine, and TAF. For our alternative agents, you can use the same NRTI backbone with the protease inhibitor darunavir boosted with either cobicista or ritonavir. And again, this can be achieved by either combining a few different tablets or it can be done as a single tablet regimen with Symptusa, which is dronviricobisustat, emtricitabine, and tenofovir alafenamide.

Stephen Small: 5:49

Excellent. So we do have a couple options there. And this leads us to a good question here. We have a lot of different medication classes we just pointed out. Michael, how do these different medication classes work?

Michael A. Deaney: 6:02

Sure. So the way that these different medications work is that patients will take these medications preemptively to protect themselves from HIV infection. The actual mechanisms of how they work, basically in early HIV infection, your lymphocytes, gut, vaginal, cervical tissue, and rectal tissue all act as reservoirs of HIV. So PrEP agents work by being active against different stages of HIV replication, basically stamping it down before it starts replicating out of control. So Truvada and Descovy, as Caitlin said, both contain tenofovir and emtricitabine. They're called nucleoside reverse transcriptase inhibitors, more commonly referred to as NUCs, since that's quite a mouthful. They were blocked reverse transcriptase, an enzyme that converts HIV RNA to DNA. The first one that came out was Truvada, and it's now one of the only generic ones as well. And it specifically contains TDF, so tenofovir-gestaproxyl fumarate, which is a prodrug of the active tenofovir. It achieves the good concentrations in all of the HIV reservoirs and, like I said, is available as an oral tablet. As far as Descovy goes, it also contains two nukes, just like Truvada. The difference highlighted here is going to be that the tenofovir prodrug is a little bit different. So it's tenofovir alafenamide, CAF, instead of TDF. Basically, its structure is modified to have a bit of a longer half-life in the plasma, allowing it to have higher concentrations in the lymphocytes and lower off-target concentrations like in the renal tubules, which is potentially why we see reduced rates of renal toxicity with this drug. But it's otherwise non-inferior to Truvada in terms of efficacy and just maybe a little less harsh on the kidneys. And then the last one is cabotegravir, which is an integrase inhibitor. It blocks the integrase enzyme to stop HIV DNA from entering the host cell DNA. It is the newest agent on the market, and it is formulated as a depot formulation that allows it to be released slowly when given as an intramuscular injection, allowing for much less frequent dosing intervals.

Stephen Small: 8:09

Great review of how PrEP meds work. And how about PEP, though? We have lamivudine, that is also a nuke, and bactegravir and dolutegravir that are integrase inhibitors, like you said before. But what about protease inhibitors that are an alternative for PEP?

Michael A. Deaney: 8:27

Yeah, so protease inhibitors will stop the new HIV viruses from making important proteins for replication, drugs like durinavir or ritonavir.

Stephen Small: 8:39

Right. And I believe cobicistat is also there as sort of a booster like ritonavir to boost the levels of darunavir is my understanding. Excellent. And then one question we get a lot from our listeners is how do these PrEP and PEP regimens differ from actual HIV treatment? Does anybody want to kind of spell out those differences there to put that in perspective? Michael, how about you help us out here?

Michael A. Deaney: 9:05

Sure. So PrEP and PEP regimens are different from HIV treatment, mostly in terms of treatment goals. With PrEP regimens, we usually use more active agents than just, say, two nukes or one integrase inhibitor. Oftentimes, we'll use multiple agents from different classes of drugs that are active against HIV in order to target different stages of its replication lifecycle to keep it at bay.

Stephen Small: 9:31

And another important point here, too, is sort of the duration we're talking about, right? Where treatment is going to be a different duration than maybe PrEP or PEP. What are the differences there?

Michael A. Deaney: 9:42

Yes, exactly. So with PrEP regimens, most of the time they're only taken for the duration where HIV exposure factors are going to be present. And then PEP is a fairly limited duration of 28 days after the exposure. However, treatment, at least as of right now in our treatment landscape for HIV, is going to be indefinite. So that's the other major difference is treatment goals and duration. Yeah,

Stephen Small: 10:07

that's a great way to put that in context. Excellent. And then, Michael, while I have you here, how effective are these PrEP and PEP regimens against HIV? We actually get that question a lot from our listeners. Since many patients are now taking these, how effective would you say these are?

Michael A. Deaney: 10:23

Both PrEP and PEP regimens are extremely effective against HIV. Specifically with PrEP, they're very effective if you're using daily oral PrEP or injectable. About 99% for sexual exposures and 74% effective for those who inject drugs and have that exposure risk factor. Typically when we counsel patients, and we try to counsel them to take it every single day, in order to keep this down, but there's some pharmacokinetic data that suggests two to four doses per week for rectal tissue and six to seven doses per week for vaginal tissue may be sufficient. Clinical data seem to support that at least four to six doses confer protection and low levels of HIV acquisition, no matter which group, though. It usually takes about seven days to max protection with oral therapy for receptive anal sex and 21 days for receptive vaginal or for people who inject drugs.

Stephen Small: 11:14

Great. And then, Caitlin, who would be eligible for these PrEP therapies? Are there certain risk factors you'd be looking for for a patient to make them eligible to even get these?

Caitlin Prather: 11:28

Yeah, so honestly, anybody who is HIV negative and is sexually active and they're not in a monogamous relationship with another HIV negative individual can probably benefit from PrEP. But specifically, some categories of folks that you may want to kind of take a closer look at in terms of determining who could benefit the most from it could be those who are having anal or vaginal sex recently and they either have a partner who is HIV positive or they're not consistently using condoms or they've also been diagnosed with an STI recently. We can also use PrEP in individuals who inject drugs with either an injection partner living with HIV or someone who shares their supplies or equipment like needles and syringes. And then the third group would be those who have been prescribed PEP in the past, so our post-exposure prophylaxis. So if we see that someone has been using PEP historically, that might show that they have some type of potential condition. risk or some type of potential exposure to HIV. So that could be another good category to look at for potential patients. But like I said, honestly, anybody who's HIV negative and they're coming in and, you know, someone's requesting PrEP, it's usually fair. There may be something that they don't want to disclose to you, you know, something that they consider private or uncomfortable discussing. So as long as they're HIV negative and don't have any contraindications to therapy, then PrEP can be used in quite a few different individuals.

Stephen Small: 12:57

And then that leads to our next question, who is eligible for PEP? PEP is indicated within 72 hours of a possible HIV exposure, whether that source has HIV or their status is unknown. And this exposure generally needs to involve blood or mucosal exposure, such as the mouth or eyes, to high-risk secretions that could carry large amounts of the virus. These secretions can include blood, breast milk, semen, and vaginal or rectal secretions. And CDC's 2025 PEP guidelines have several visual algorithms that help to really determine if a patient needs PEP based on the exposure, since these cases can be pretty complex. And I recommend it as a helpful resource if there are any questions. A key point to really remember from all this is that the 72-hour mark after exposure is key. If we pass this time frame, it's generally too late to start PEP, and patients may need different care and monitoring. That actually leads us to our next question. What lab tests are required when we're starting a patient or maintaining a patient on PrEP and PEP? What are some things maybe pharmacists should be looking out for for results?

Michael A. Deaney: 14:09

Sure, so I can take this one. So I think one of the very most important lab tests that were required for PrEP initiation is going to be an HIV test. So this should be obtained at baseline and then periodically as well throughout treatment. Because if you are positive for HIV and started on PrEP, you are potentially being started on an inadequate regimen. And this could lead to potential formation of resistance for when you need to form a complete regimen for HIV treatment later. Other important things include serum creatinine. This is especially important for TDF-based regimens because there are serum creatinine cutoffs for using either TDF or TAF-based regimens. And that's also monitored periodically throughout. You can see here every 6 and 12 months. And also other STIs. Patients who are on PrEP are at a higher risk for additional STIs outside of just HIV. And having other STIs that are active infections while being exposed to HIV also heightens your risk for acquiring HIV. So at baseline, all patients should be tested for syphilis as well as gonorrhea and chlamydia. and the men, again, periodically thereafter. It's recommended every three months for additional STI testing for transgender women and men who have sex with men, just due to higher risk of acquisition, and then every six months for other populations. Other important things include a lipid panel at baseline, and then every 12 months thereafter for patients on tenofovir alafenamide, due to a slightly higher risk of lipid abnormalities, and then baseline testing for hepatitis B and hepatitis C as well. These are also transmissible viruses that should be caught if they're there, and this is a great opportunity to get those patients into care.

Andrea Darby-Stewart: 15:54

The one comment that I had on this was that I think that under hepatitis C at baseline, we need to have a reminder to everyone that all of our patients who are 18 and older should be screened for hepatitis C if they have not been screened in the past. And this implies that there are only a subset of people who might take oral PrEP that would need to be screened for hepatitis C.

Stephen Small: 16:21

That's excellent. Thank you for that call out there. And I think it's also worth noting that injectable PrEP using cabotegravir has a slightly different monitoring approach that you may see. Since it doesn't have tenofovir in the formulation, it's not necessarily required to check renal function labs, but monitoring for HIV and other sexually transmitted infections is still generally the same, usually timed up with the every two-month visits to actually administer the med. And then how might that contrast with PEP if we're sort of looking at post-exposure prophylaxis. Is that lab testing similar?

Michael A. Deaney: 16:54

The lab testing is extremely similar. So as you can see here, we are also testing at baseline and then periodically thereafter for HIV antigen antibody, hepatitis B, hepatitis C, other STIs including syphilis, gonorrhea, and chlamydia, pregnancy as well, and then serine creatinine as well as liver enzymes.

Stephen Small: 17:18

And then this is actually a good segue into our next question from both a prescriber and pharmacist perspective. Andrea, how do you choose a PrEP regimen for a patient? We actually have a patient example here that can maybe help us out, Lenny. He's a 24-year-old cisgender man who has sex with men, wants to start PrEP since he prefers to not really use condoms during intercourse. And I'm curious, what questions would you ask a patient first? And what prep option might you even advise for Lenny here? Andrew, maybe you can start from the prescriber perspective.

Andrea Darby-Stewart: 17:52

Yeah, absolutely. Well, you know, as a primary care physician, I need a little bit more information about Lenny than what we provided here, which is obviously the point of this discussion. So, you know, for a Me, I want to know, I want to clarify that he's having sex with cisgender men rather than trans men and want to know what his partner's status is in terms of HIV for future reference, if he does know, if he does have a partner who happens to be positive and then has sex or sexual contact with other partners as well. How many partners does he have? What is his sexual activity like? Where do body partners connect, basically, for him, because that will have an implication as well. And then how good does he think he's going to be at taking his medications? Taking a medication on a daily basis versus using an as-needed PrEP might be beneficial for him, depending on how frequently he does have sex. And then also, we have to get down to the brass tacks of how much these medications cost and whether or not he has an insurance that will cover one or another of the medications that's available currently.

Stephen Small: 19:11

And Caitlin, is there anything added from a pharmacist perspective you might be wanting to ask or look for in terms of info?

Caitlin Prather: 19:20

Sure. So with regard to choosing a PrEP regimen, it's definitely very patient-specific. There are going to be many patients who are eligible for any of the products, and then it really comes down to patient preference and what's going to work best for them. When that happens where the patient doesn't have any contraindications to any of them, I like to have that conversation with them and say, whatever PrEP agent you can adhere to is the best one for you. If you're able to be 100% adherent to a tablet and it would be inconvenient for you to come into the office to get injections, then great, go with an oral PrEP agent. If cost is your number one concern and maybe you don't have insurance or you don't have insurance that covers PrEP very well, then sure, do the generic. But for some patients, it's really tough to take a pill every single day. And so they would prefer to do the injection. So really, it's just kind of whatever the patient prefers and they're going to be able to adhere to. Otherwise, it does come down to just some of those key differences. So, you know, for example, if the patient has renal dysfunction, then maybe our injectable would be best, or there might be certain drug interactions that are only with some of them. So then you just have to kind of consider those individual factors. But there are going to be many patients who who really qualify for any of the three agents.

Stephen Small: 20:37

And Andrea, you mentioned a moment ago kind of as-needed dosing. I think you're referring to the 2-1-1 dosing for PrEP. What is that, and how often do you actually see this used in your practice?

Andrea Darby-Stewart: 20:50

Absolutely. It's a great question. So 2-in-1 dosing is used for people who have planned high-risk sexual activity, and it can be referred to basically as on-demand dosing. So if patients have infrequent intercourse and they can time when that might happen, we would have them take two tablets anywhere between 2 and 24 hours prior to having sexual activities, and then they take a second dose at 24 hours after intercourse and a third dose 24 hours later. It's not FDA approved, but patients find this helpful, particularly if they are not having intercourse regularly and still want to protect themselves with a pharmacologic method.

Stephen Small: 21:35

And then, Michael, we talked earlier about cabotegravir being a newer option and that it's an intramuscular injection. How is that exactly administered for PrEP? I know a lot of our listeners have questions about the steps to that. Is it just like any typical injection or are there maybe some other things to think about here?

Michael A. Deaney: 21:54

Sure. So I guess some basic steps to administration. Usually the way it's done is you obtain the vial of the cabotegravir. It's about three milliliters of drug, so a pretty substantial volume. Allow it to reach room temperature before administration since it is typically refrigerated beforehand. We de-shake the vial for about 10 seconds to get a uniform suspension before swabbing it, attaching the included adapter in the kit, and then screwing on a syringe. The kit does contain two different sizes of syringes depending on patient weight. So there's a longer syringe attached for patients with a BMI of greater than 30. And then you draw up about their three milliliter dose into the syringe and administer it within two hours of preparation, noting not to store the dose in the refrigerator as it can increase patient discomfort. So other things to know about administration of cabotegravir. For first dose, sometimes patients will use an oral lead-in, so the 28 days of oral cavitagravir, which is supplied by the manufacturer, versus that they'll go straight to the injections. There's no strong preference between these two in terms of efficacy or anything like that, but you might consider an oral lead-in for patients that are a bit more nervous about having a long-acting injectable or potentially having have a history of hypersensitivity reactions where you might want to see how the drug does on a short-acting basis before something long-acting.

Caitlin Prather: 23:24

I probably have about maybe 100 to 150 patients who are on Apertude. We've had very, very few who have chosen to use the oral lead-in. It's mostly those patients who either have a long history of drug allergies, so they're a Or they've also just had some maybe some bad experiences in terms of drug side effects in the past. So they want to, you know, kind of try it out. I always have to give them that warning, though, of let's say if you have a side effect and it's more of a GI type side effect with the oral edin, that doesn't necessarily mean that that's going to translate over to the injection. So we have to kind of take those, you know, whatever side effects that they might get from the oral weed in with a grain of salt because it's not the exact same product. But yeah, we don't have very many patients opt to do it. We've probably had maybe two or three total.

Michael A. Deaney: 24:12

Another thing, too, about the intragluteal injections, they can definitely hurt. That's the most common side effect with these meds. And I'd say pretty much every patient that we've administered cabotegravir to in any form has complained of this, but it doesn't normally stop them from using the drug, I'd say. For patients where it feels severe enough, we'll tell them to use acetaminophen or ibuprofen as well. Oh, and one other thing about administration that I think is a good pearl is that fillers and implants are typically excluded from the trials. So it's unclear about, and it can certainly vary depending on the filler implant as well in the gluteal muscle. So it's something to consider and something to ask patients if we're considering them for cabotegravir injections, just to make sure that we don't potentially administer something that isn't actually going to get into the muscle because there's an implant in the way.

Stephen Small: 25:09

That's really unique. I didn't think about that. Thank you for pointing that out. And how long does maybe that pain last after injection? I'm sure it's variable, but is it like a week, maybe a day? What have you seen in your experience, Michael?

Michael A. Deaney: 25:26

I'd say it's relatively variable. I've talked to patients and they've said that they feel fine by the end of day. Sometimes it lasts for a couple of days extra. Yeah, it's not normally too terribly long. Definitely gone within a week, I'd say.

Stephen Small: 25:37

That's great. Thank you for that insight. That's super helpful. And now that we've kind of covered PrEP, The next question becomes, how do you choose a post-exposure prophylaxis regimen? Andrea, what's your take on that from a prescriber perspective? And then I can move to Kayla and Michael from the pharmacist side of things.

Andrea Darby-Stewart: 25:59

So again, for me, a lot of it is going to be related to coverage and whether or not, you know, what my organization is covered, if this is a healthcare worker exposure for my patients, insurance coverage as well. Those are the two big areas that tend to be the focus for my team.

Stephen Small: 26:19

Great. And Caitlin, anything from your perspective for PET, if that's prescribed, that you're looking at from a pharmacist's point of view?

Caitlin Prather: 26:27

Yeah, really, it's primarily, like Andrew said, the cost is definitely a big component of it. And then with the updated guidelines, We now have some options for single tablet regimens. So that also can play a role in terms of, you know, finding what's going to be the best option for the patient in order for them to maintain good adherence to that regimen.

Stephen Small: 26:46

Excellent. And when we're writing these prescriptions, what are common errors to watch for with these meds? It's a very unique class and there's a lot of meds, a lot of different names. What are some things you watch out for? Maybe how you mitigate those risks?

Andrea Darby-Stewart: 27:04

Oh boy. Yeah. This is all about names, naming conventions, right? Like my head sometimes spins when I look at all of these names. And so I have an electronic healthcare record. I'm able to set up a preference list, which help reduce the risk for medication errors, but I try not to use abbreviations for these medications. And then one of the things that we want to do is make sure that Tenofovir actually has the entire form written out as opposed to just writing TNF, making sure you're including the alafenamide versus the disaproxyl fumarate.

Stephen Small: 27:42

I really like those points, Andrea. And it's a good time to specify that tenofovir alafenamide and tenofovir disaproxyl fumarate are not interchangeable one-to-one. Even though both can be used for PrEP and PEP, each salt form has different dosing. And also, watch cabotegravir products carefully. We know from this discussion, IM cabotegravir alone is approved for PrEP, but the similar cabotegravir plus rilpivirine injection product on the market is only intended for HIV treatment, not PrEP. So keep that in mind to avoid mix-ups. And from the pharmacist's perspective, what do you insure is on these prescriptions when you receive them?

Michael A. Deaney: 28:25

Yeah, I think... Specifying the indication in the SIG is important while noting also the privacy of the patient. So wording it discreetly what it's for and then specifically the duration for sure. So if it's daily oral prep, strict daily adherence, preferred if the 201 method is going to be utilized, listing that on the SIG as well. And then write the duration and the importance of adherence for PEP for 28 days.

Caitlin Prather: 28:56

Really, I mean, they're relatively straightforward. I think the biggest thing is to look out for those errors with the nomenclature like Andrea was discussing. The biggest thing I would say is to really continue that full regimen for PEP to make sure that, you know, they do continue that for the full 28 days. They don't discontinue just because they are not worried about it anymore or whatever. You know, make sure that they're completing that therapy and having that follow-up with their provider at the end in order to get those labs. And for PEP, Same thing, just to ensure that there are no lapses in adherence, so ensuring that there are enough refills and that it's very clear that this should be taken daily and not on an as-needed basis.

Stephen Small: 29:39

And then we're getting questions from our technicians in the audience. Are there any specific dispensing considerations for technicians with these medications they should be looking for?

Michael A. Deaney: 29:50

Yes. I think when handing over these medications, I think it's very important to to keep the meds in the original containers due to high costs, watch the quantities and durations on the prescriptions to make sure that they match the appropriate indication, utilizing those combo tablet options to improve adherence where possible, and then having the med supply on hand to start therapy ASAP. We definitely want to make sure that if a pharmacy is able to dispense Pref or Cup, it's going to be available at the ready. I think another important thing too, especially when handing the medication over to the patient, is just to be discreet, both about what the name of the medication is as well as the indication for it, just in case the patient isn't comfortable with that kind of thing being said out loud, especially in a more busy pharmacy. And then I think technicians as well as pharmacists can kind of watch out for some errors as far as the medications go. I know that Andrea pointed out a number of really, really good observations. The only ones that I'll add are that pediatric dyscovy does exist and is at a lower dose than adult dyscovy. It's not often kept in stock necessarily in many retail pharmacies, but it's definitely something to be aware of just because it says dyscovy or just because it says FTAF, making sure that dose does align since there are multiple doses.

Caitlin Prather: 31:10

Yeah, I agree with everything that Michael said. Just a few additional things. considerations would be to keep in mind that there are some products that have both the generic and the brand name products still available. So Truvada is kind of the good example of that right now, where the brand product is still available. So some patients may be getting that through like a patient assistance program or a coupon card or something like that, but we can't use those coupon cards from the manufacturer when we're talking about the generics. And then another is just if you do see a PrEP prescription, so again, for Truvada or Descovy, or even Apertude, and it's being filled less frequently than it should, so it's not really meeting that appropriate day supply, that could imply that that patient is having less than ideal adherence. And that could be something to just bring up with your pharmacist so that they can have that conversation with that patient as well.

Stephen Small: 32:01

So Andrea, what are some key counseling points about these meds you might want to share with patients that you sort of focus on in your practice?

Andrea Darby-Stewart: 32:09

That's a great question. You know, I really emphasize the need to take the medications on a daily basis to optimize the protective benefits of the medications. I try and emphasize 100% barrier method use for patients, whether or not that's an internal condom for people with vaginas or an external condom for those with penises, and want to make sure that they understand the need for regular follow-up to ensure that their HIV- status doesn't change while they're taking this medication because that can impact future choices for their HIV treatment methodology. If somebody is using PrEP intermittently, that's kind of an important thing to keep in your, in the case of my patient, their travel go-to bag so that they actually have the medication on hand when they need it. And just emphasize that we are really here to provide them with great care and appreciate their willingness to have this conversation with us.

Stephen Small: 33:10

And any adverse effects you maybe warn patients about ahead of time that you see commonly?

Andrea Darby-Stewart: 33:17

You know, we talk about things that seem to pop up on almost every single medication's list of problems. So nausea, diarrhea, headaches, fatigue, uncommon for patients to develop the things that we continue to screen for, things like kidney injury or hyperlipidemia. But that's why emphasizing those follow-ups and appropriate laboratory follow-up for patients on these medications is done in our office.

Stephen Small: 33:45

That brings up common questions we get around billing considerations for these PrEP and PEP meds. What are some important things to consider here?

Caitlin Prather: 33:54

Sure, billing considerations. Definitely a great and important question. I'll start with post-exposure prophylaxis. So if it was an occupational exposure, that's usually covered under the patient's workplace injury compensation. For other general exposures outside of the workplace, so for NPEP, insurance will often cover it, and there are some state governments that provide additional financial assistance, likewise for sexual assault exposures. PrEP can be a little bit more tricky. In general, most private and Medicaid plans do cover PrEP, but that sometimes means that they cover all PrEP agents, and sometimes it means that they only cover one, which they would usually pick the least expensive product, which would be the generic of Truvada, which is emtricitabine with TDF. Also, Medicare Part B does cover PrEP and related services like labs without any cost sharing. And then there are, again, some states with additional assistance programs. The drug companies also have some really nice patient assistance programs to help out with patients who are uninsured. For injectable aptitude, there's a lot that we could go into that we just don't have time to today. But some key considerations are that the injection may be covered under the patient's pharmacy benefit or their medical benefit through specialty pharmacy dispensing. And then some insurance plans are only going to allow it to be billed under the medical benefit of the insurance, and clinics would then have to acquire that medication through buy-and-bill practices. So it's very... dependent on each individual plan. I really haven't found any specific trends. So some places will fill it very easily through the specialty pharmacy and others are kind of forcing it to go through buy and build. So that does vary a lot when it comes to injectables because then we're looking at specialty pharmacies rather than your kind of more typical retail community pharmacies.

Stephen Small: 35:43

And some audience members are asking right now, what are upcoming changes or developments with PrEP and PEP to keep in mind? And in fact, FDA approved lenacapivir or Yeztugo in June 2025 as another option for PrEP. It's a unique antiretroviral, being the first-in-its-class capsid inhibitor, and it stops the virus from assembly. And its tablet and injectable formulations have already been approved for HIV treatment. Now, for PrEP, lenacapivir is a long-acting subcutaneous injection that can be used as monotherapy. And patients first start with a two-day lead-in phase using an injection along with oral tablets. And then for maintenance injections, these are given as two separate 1.5 ml doses into the abdomen every six months. Now, it's been approved for adults and adolescents down to 35 kilos. And it's been shown to decrease sexually transmitted HIV infection in cisgender men and women. transgender men and women and non-binary people as well. However, it may take time for this med to become available on the market for purchasing and the estimated costs are high, possibly over $20,000 per year. But the manufacturer already has a cost savings program in place and we'll see how that goes. And stay tuned for developments as we learn more.

Narrator: 37:02

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