Academy Exchange

 View Only
  • 1.  PrEP for Adolescents.

    Posted 04-12-2022 10:15
    Hello,

    I'm a FNP/HIV specialist practicing in South Florida. We have been prescribing  PrEP for many patients (ages 18 and above) since 2 years. Yesterday for the first time we had a female patient aged 15 who "wants" PrEP (grandmother consents). She does fit in the CDC criteria to receive PrEP (multiple sex partners, unprotected vaginal sex, 2 episodes of STI). We couldn't find specific guidelines for this age group related to PrEP. Is it safe to give PrEP at this age? Where can I find CDC guidelines related to this topic? I called CDC PrEP helpline (1855 448 7737) and left a voicemail, still waiting for a reply.

    Thank you,


    ------------------------------
    Rajesh Waghmode
    APRN, FNP-C
    HIV-Specialist
    Miami, FL
    ------------------------------


  • 2.  RE: PrEP for Adolescents.

    Posted 04-12-2022 16:17
      |   view attached
    A great topic for discussion. PrEP is absolutely appropriate and safe for adolescents. The guidelines do not vary much but you should take the weight of the patient into consideration >35KG for appropriate dosing. 
    Page 62 of the 2021 CDC guidelines give a brief statement of support of PrEP for Adolescent Minors. 
    Kudos for this young person taking control of their sexual health 

    https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf

    ------------------------------
    Quintin Robinson
    Absolute Care Medical Center & Pharmacy
    Atlanta GA
    ------------------------------

    Attachment(s)



  • 3.  RE: PrEP for Adolescents.

    Posted 04-12-2022 16:18
    Emtricitabine/tenofovor DF  (generic Truvada) is indicated for PrEP for adolescent males and females weighing at least 77 lb. Adherence is more of an issue for adolescents so we try to see adolescents on PrEP monthly rather than every 3 months. Descovy is not indicated for natal females. Cabotegravir injection (Apretude) would also be appropriate for your patient but the logistics are more challenging.

    ------------------------------
    Peter Shalit MD
    Seattle WA
    ------------------------------



  • 4.  RE: PrEP for Adolescents.

    Posted 04-12-2022 16:18
    Definitely indicated.
    No state of which I am aware prohibits adolescent PrEP. But not addressed as the statutes allowing us to treat STIs (including HIV) without parental consent were drafted prior to PrEP.
    I write these prescriptions instead of asking my NPs and PAs to.
    I personally believe it would be medically irresponsible not to write PrEP for an adolescent such as yours if they weigh over 35kg.

    Brian R. McMurray, MD, FACP, FACEP, AAHIVS
    Medical Director, Music City PrEP


    Sent from my iPhone with apologies for mistypes and auto correct insertions




  • 5.  RE: PrEP for Adolescents.

    Posted 04-12-2022 16:18
    At my practice, we have prescribed PrEP for adolescents.  

    The CDC guidelines also recommend it (https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf)
    It's on page 13, --For both men and women, PrEP with daily F/TDF is recommended for HIV prevention for sexuallyactive adults and adolescents weighing at least 35 kg (77 lb) who report sexual behaviors that place them at substantial ongoing risk of HIV exposure and acquisition. (IA)1 

    I'm in NYS where we have a section in our NYS DOH guidelines on adolescents (https://www.hivguidelines.org/prep-for-prevention/prep/#tab_2)
    PrEP for adolescents: On May 15, 2018, the FDA approved the use of TDF/FTC as PrEP in adolescents weighing ≥35 kg (~77 lb.) [FDA 2018]. The Centers for Disease Control and Prevention and the International Antiviral Society–USA previously extended the indication for TDF/FTC to include PrEP for adolescents at increased risk of acquiring HIV [Marrazzo, et al. 2014; CDC 2017]. To date, there is no evidence of increased TDF/FTC toxicity in adolescents taking this combination as part of an ART regimen. TDF/FTC as PrEP was safe and effective in adolescents, with no renal events or bone fractures noted [Hosek, et al. 2017]. Concerns regarding bone loss in younger age groups have been raised, with 2 studies reporting a decline in bone mineral density [Havens, et al. 2017] [Hosek, et al. 2017]. Bone density changes associated with TDF use are reversible on discontinuation in adults [Grant, et al. 2016] and in young men who have sex with men, aged 18 to 22 years [Hosek, et al. 2017]. Data on bone density recovery after discontinuation of TDF/FTC as PrEP is not available for adolescents younger than 18 years. Studies are in progress to determine safety of the drug for adolescents over longer periods of time. TAF/FTC was approved by the FDA for use as PrEP in adults and adolescents in October 2019. There are no specific data on bone safety in adolescents taking TAF/FTC as PrEP; however, given the more favorable bone biomarkers of TAF versus TDF, TAF may have an advantage in MSM and transgender female adolescents who have not achieved bone maturation, but this advantage is theoretical, and without clinical data a clear recommendation cannot be made at this time. Modeling studies have shown the potential for PrEP to be highly effective at reducing HIV incidence in adolescent MSM communities, through both direct use by adolescents and indirectly by reducing HIV prevalence among their young adult sex partners [Goodreau, et al. 2018; Hamilton, et al. 2019].

    ------------------------------
    Alexandra Danforth
    Trillium Health
    Webster NY
    ------------------------------



  • 6.  RE: PrEP for Adolescents.

    Posted 04-12-2022 16:18
    Hi Rajesh,

    As long as she weighs at least 35kg, both Truvada and Apretude would be FDA indicated for her situation.

    ------------------------------
    Adam Zweig
    AIDS Healthcare Foundation
    San Diego CA
    ------------------------------



  • 7.  RE: PrEP for Adolescents.

    Posted 04-13-2022 09:16
      |   view attached
    Hello,
    I would definitely prescribe PrEP for her. There is an excellent article in Pediatrics in Review Jan 2022 journal, I included it as an attachment. Basically, as long as the teen weighs at least 77 pounds- it is safer to prescribe than not to, due to risk factors. Also, per the article, "There are no states that explicitly prohibit autonomous consent for PrEP in minors." Let me know if you have trouble with the attachment.
    Erika

    ------------------------------
    Erika Shea
    PHMC/Congreso
    Philadelphia PA
    ------------------------------

    Attachment(s)



  • 8.  RE: PrEP for Adolescents.

    Posted 04-13-2022 09:16
    Hey, Rajesh-

    I'm a Peds ID Specialist who provides PEP/PrEP for adolescent kiddos in the Bronx as well. Providing PrEP for young teenage girls is challenging but rewarding at the same time. There are no issues but I would offer a suggestion; if she's not using anything for birth control, have the conversation. In young teenage girls, we don't do a good job discussing contraception and how to avoid unplanned pregnancies. If you don't provide GYN care for adolescent females, I would recommend you refer her so she is on the path to understanding the importance of GYN care and birth control. I would have this discussion at every visit, they are usually very receptive.

    ------------------------------
    Michelle Ogle
    Bronx NY
    ------------------------------



  • 9.  RE: PrEP for Adolescents.

    Posted 04-13-2022 09:16
    Thank you everyone,

    Yes, we did prescribe PrEP for that pt. Thank you for providing the references based on which we updated our policies. We also received confirmation from CDC.

    ------------------------------
    Rajesh Waghmode
    Coral Springs FL
    ------------------------------