Prescribing PrEP to adolescents and young adults Hakuna Truvada: Maureen D. Connolly, MD Henry Ford Health System May 31, 2018

What we’ll cover today Young people and HIV Basics of prescribing PrEP Data on PrEP and youth Minor consent laws

HIV in the United States http://www.cdc.gov/nchhstp/newsroom/2016/croi-press-release-risk.html https://www.aids.gov/hiv-aids-basics/hiv-aids-101/statistics/

Why? WHY NOT: Not the focus of early education and advocacy efforts “Explaining disparities in HIV infection among black and white men who have sex with men: a meta-analysis of HIV risk behaviors” AIDS, 20071 53 studies published between 1980 and 2006 Compared with white MSM, black MSM reported less overall substance use and fewer sex partners. There were no statistically significant differences by race in reported unprotected anal intercourse, commercial sex work, sex with a known HIV-positive partner, or HIV testing history. “Behavioral risk factors for HIV infection do not explain elevated HIV rates among black MSM. Continued emphasis on risk behaviors will have only limited impact on the disproportionate rates of HIV infection among black MSM.” Not the focus of early education and advocacy efforts Less likely to have access to healthcare Segregated sexual networks

PrEP = pre-exposure prophylaxis for HIV One pill once a day to prevent HIV. Data! The tool box! Sex positivity! NEMJ 2010: The iPrEx study compared Truvada with a placebo pill in nearly 2,500 gay and bi men and transwomen in six countries. All of the participants also got safer sex counseling and condoms, regular sexually transmitted infection (STI) check-ups and treatment, and HIV testing. The analysis showed that the group assigned to receive Truvada had a 42% reduction in HIV risk compared with those who received placebo. However, the Truvada group included people who were offered Truvada but did not take the pills. When the researchers looked at data only from people with detectable levels of the drugs in their blood (a sign than the medication was being taken regularly), they found that transmissions dropped by as much as 92%. Further analyses indicate that drug levels corresponding to daily use are associated with 99% protection against HIV.

Tenofovir = NtRI, Emtricitabine = NRTI Triumeq (abacavir – NRTI, lamivudine – NRTI, dolutegravir – integrase inhibitor

How to prescribe PrEP2 3 big concerns: HIV, Cr, Hep B, bone density Allen E, Gordon A, Krakower D, et al. HIV preexposure prophylaxis for adolescents and young adults.

PrEP and Adolescents: CDC guidelines Kid

ATN 113: An HIV pre-exposure prophylaxis (PrEP) demonstration project and safety study for adolescent MSM ages 15-17 in the United States2 78 HIV-uninfected MSM 15-17 years, reported HIV risk behavior in the past 6 months (32 lost to follow up) Safe and well tolerated, no abnormal laboratory results, including kidney function DEXA scans at 48 weeks, data still being analyzed 3 young men seroconverted, despite provision of PrEP, likely high background incidence Majority achieved protective drug levels during monthly visits, adherence dropped with quarterly visits Approached 290 youth August 2013 - September 2014, study lasted 11 months The mean age of the study group was 16.5 years. Nearly a third were black, a similar proportion identified as mixed or other race/ethnicity, 21% were Hispanic/Latino, 14% were white and 3% were Asian. A majority (58%) identified as gay and 28% as bisexual. They were most successfully recruited online rather than through gay venues. Most participants were currently living with their families, but 15% said they had been kicked out for being gay. The men had two sex partners during the past month, on average, and 60% reported condomless receptive anal sex with their last partner; 17% said they had ever been paid for sex and 15% had a positive STI test.

Minor Consent https://www.michigan.gov/documents/mdch/Michigan_Minor_Consent_Laws_for_Sexual_Health_292774_7.pdf

Minor Consent http://legislature.mi.gov/doc.aspx?mcl-333-5127

From MDHHS Division of HIV and STD Programs: 1.  PrEP prescriptions for a minor in the absence of a recent STI and not prescribed in a Title X clinic requires parental consent 2.  PrEP prescriptions with or without a recent STI at a Title X clinic does not require parental consent 3.   PrEP prescriptions with a recent STI in any type of provider setting does not require parental consent

Talking about PrEP with young people It is one tool in our HIV prevention toolbox Most effective = what works for the patient If it doesn’t fit in a young person’s life, that’s OK! Talking about PrEP with young people

Access to PrEP for young people is important!

My e-mail: mconnol1@hfhs.org References Millett GA, Flores SA, Peterson JL, Bakeman R. Explaining disparities in HIV infection among black and white men who have sex with men: a meta-analysis of HIV risk behaviors: AIDS. 2007;21(15):2083-2091. doi:10.1097/QAD.0b013e3282e9a64b. Allen E, Gordon A, Krakower D, et al. HIV preexposure prophylaxis for adolescents and young adults. Curr Opin Pediatr 2017;29:399–406 Hosek S et al. An HIV pre-exposure prophylaxis (PrEP) demonstration project and safety study for adolescent MSM ages 15-17 in the United States (ATN 113). 21st International AIDS Conference, Durban, abstract TUAX0104LB, 2016. My e-mail: mconnol1@hfhs.org