Scott Webb (Host): You may have seen some commercials for medications called PrEP, Pre-Exposure Prophylaxis, and wondered what exactly these drugs are for. Well, you came to the right place by listening to the podcast today because I'm joined by doctors Amy Hite and John Tomich. They're both Summa Health Medical Group physicians at the Care Center, and they're here today to tell us what PrEP is, who it's appropriate for, and how patients can access PrEP at Summa Health.

 This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb.

Want to thank you both for joining me today. We're going to talk about HIV prevention and PrEP and what all that means and how folks can get access to it and all that good stuff. So, Dr. Tomich, I'll start with you. What is PrEP and how effective is it at preventing HIV infection?

John Tomich, M.D.: So PrEP, which stands for pre-exposure prophylaxis is one to two medications that are used both for the treatment of HIV, but in this specific situation, they're used to be taken prophylactically to prevent those at risk of contracting HIV from acquiring it; whether that be through sexual transmission or through IV drug use.

Scott Webb (Host): And Doctor, how effective is PrEP?

John Tomich, M.D.: To be most effective, it does need to be taken consistently to ensure that there are adequate drug levels in the system to ensure there's adequate protection and levels of drug to prevent transmission. When taken consistently, it's proven to be 90% or more effective at preventing transmission when the risk factors are sexual in nature and in terms of IV drug use and those that share needles, it's greater than 70% effective at preventing transmission of HIV.

Host: Yeah, it's really amazing. I'm about to turn 55, and so I've sort of lived through this, all of this with HIV and AIDS, and it's just really amazing how far it's come and how effective PrEP is. So Dr. Hite then, what are the medications for PrEP and how are they administered?

Amy Hite, M.D: So there are currently three FDA approved medications for PrEP that are available. There are two oral medications and one injectable medication. The two oral medications are Truvada and Descovy. Truvada was the first medication that was approved for PrEP all the way back in 2012. It is a medication that's taken orally.

It's a combination of two different HIV medications that are together in one pill. It's typically taken daily and it's approved for all at-risk populations and genders. The next oral medication is Descovy, which came out a few years ago in an indication for PrEP. It is also an oral medication. Again, a combination of two different HIV medications, very similar to the ones that in Truvada, but these are slightly different and have less potential effects on the bones and kidneys long-term compared to Truvada.

It's usually taken again daily. The difference of Descovy and Truvada in addition to the renal and bone risk is that Descovy has only been studied in patients that were assigned male at birth, so it's only approved for those patients at this time. There are studies, however, that are looking at it for those who are assigned female at birth with regards to PrEP. And then the final medication that is approved for PrEP is a long-acting injectable medication that's goes by the name of Apretude.

It is in a different class of medications than Truvada and Descovy. It's typically given by an intramuscular injection. So you have to get that at the doctor's office every eight weeks. And when done on schedule, it's proven to actually be superior to oral PrEP, most likely, because patients don't have to remember to take a pill every day.

Host: Sure. So Dr. Tomich, you talked about those at the greatest risk, but let's talk a little bit more just specifically about the patients you know, who should really think about starting PrEP?

John Tomich, M.D.: Identifying the right patients for PrEP is an important part of the process. In this country, a lot of times, gay bisexual men and other men who have sex with men are at an increased risk for acquiring HIV. So those are definitely at risk group to screen for PrEP and potentially initiate PrEP.

Also, those that have multiple sexual partners, those that have inconsistent condom usage with their partners. Anybody who has had a prior STI in the past, so having been treated for gonorrhea, chlamydia, or syphilis previously. Anybody who has a known partner with HIV or an HIV status unknown, especially if the partner with HIV is not linked into care and taking medicines consistently. Anybody who might be engaging in sex for either drugs or money, and then those individuals who use IV drugs, especially with known sharing of needles while they use.

Host: Yeah. And, Dr. Hite, maybe you could talk a little bit more about what patients can expect. You know, when they come for a visit for PrEP, when they begin to have these conversations, what can they expect?

Amy Hite, M.D: Yeah, that's a good question because hopefully, some of those conversations are starting to happen maybe at just your routine healthcare appointments. That's what we would ideally like to see. But if you are talking either with your primary doctor about PrEP or if you've actually been referred to a different specialist for PrEP, there are some things that are going to happen pretty consistently at those visits, no matter where you're accessing your PrEP.

And a lot of those visits are going to be focusing on history and the sexual history, of course, is very important. Substance abuse history is very important because we're really trying to identify does this patient have significant risk factors for the acquisition of HIV. So a risk assessment is very important, and that risk assessment is pretty in depth sexual history and including history of prior sexually transmitted infections and those sorts of things.

Then of course you're going to have a physical exam, and that physical exam is going to include, certain types of appropriate sexually transmitted infection tests or swabs a lot of times, depending what areas need to be evaluated for STDs. And then we need to do some additional labs, and those are going to be blood work typically to determine HIV status, evaluating somebody's baseline kidney function, looking at some other STDs, screening for different types of hepatitis and those types of things.

 It's very important to know a person's status before they start PrEP so we definitely have to screen everybody consistently for HIV, not only at that very first PrEP appointment, but then really at every PrEP appointment moving forward. So what typically happens in follow up visits then, is that a patient would have HIV testing done every three months if they're on oral PrEP, because patients will come in every three months for assessments and evaluations, and then because the injections are done every two months, then a patient who's on Apretude for PrEP would have to get HIV testing done for those appointments every two months.

Host: Yeah, it's good to take folks through that, obviously, you know, initially especially examination, full patient history, lots of honesty and transparency, and then some work to be done along the way as well. Dr. Tomich is PrEP, the kind of thing where folks can just kind of get it anywhere. Maybe you can take us through that, where the places and providers, where potential patients, folks at risk have been thinking about it, where they can find PrEP.

John Tomich, M.D.: So there's a couple different avenues that a patient can get on PrEP or get pointed in the right direction of who to get PrEP from. A lot of primary care offices, so the outpatient family medicine clinics, private doctors, internal medicine centers, would be able to prescribe if they're comfortable or will be able to get a patient referred to somebody who is prescribing PrEP.

 Likewise, some OBGYNs, for female patients can prescribe PrEP and do prescribe PrEP in their GYN clinics. Any HIV or other sexual health kind of clinics, community clinics are usually good places for patients to access PrEP. And then patients can also reach out to their county health board, health department and they either can usually prescribe PrEP there or again, know the appropriate channels of how to get a patient linked into a physician's office that is actively prescribing PrEP.

Host: Dr. Hite, we wrap up here, we think about Summa specifically, where can a patient access PrEP.

Amy Hite, M.D: Thanks for asking that because we want to get as many people who are at risk on PrEP as possible. When we look at statistics across the United States, there are many, many people who are eligible for PrEP who are not accessing PrEP. And so that's what we wanted to try to do here is make sure that people know about it, but then also know where can they go to access it. And a patient at Summa, can access PrEP in many different avenues, which is good. I think, like Dr. Tomich said, the good place to start with that is just talking to your primary care provider and whether that be, family medicine, internal medicine, just your local community doctor that you see, ask them, start a conversation about PrEP.

If they're not comfortable prescribing PrEP, then they can refer to a couple of different places at Summa. One of those is the Care Center, where Dr. Tomich and I practice. And the Care Center is a clinic that is focused on HIV treatment and prevention. The patients can be referred by their PCPs or they can call the Care Center directly at 330-375-4851. Summa also has a Pride Clinic, which is for patients that identify as LGBTQ+. And the providers there are knowledgeable about administering PrEP, and that's another great place to access it at Summa. Part of access to PrEP though too, is not just where you can go, but how can I get this medication?

Like, how can I get this medicine and all these labs that we talked about paid for. And so, that's another thing that many patients may have as a barrier to starting PrEP. Under the Affordable Care Act, PrEP medications and PrEP labs must be covered for free. And so accessing PrEP is something that is readily available to most patients at very little or no cost.

There are also patient assist programs from the state and from the different drug companies. And the providers at Summa are knowledgeable about all of those different programs and can link patients into those programs to access. And additionally, anyone who's interested in PrEP can also visit Summas website. And if you search for the Care Center under that website, not only can you learn more about the Care Center and the providers there, but there are links for additional informational websites, and some of those websites include PrEP.

Host: Yeah, that's awesome. Actually, and that website is summahealth.org/care-center, summahealth.org/care-center. This has been great today. Nice to meet both of you. Great to talk through this. As I said, a lot of great information. We hope listeners agree. Thanks so much.

Amy Hite, M.D: Thank you for having us.

John Tomich, M.D.: Thank you for having us.

Host: And if you found this podcast to be helpful and informative, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Stay well, and we'll talk again next time.