Thread by @BIDMC_IDFellows, 1/Featuring some highlights from @douglaskrakower 's PEP/PrEP talk at the advanced STD [...]

1/Featuring some highlights from @douglaskrakower 's PEP/PrEP talk at the advanced STD intensive course today!

Let's start with this pretty slide on antimicrobial STI ppx after exposure

ARE YOU READY for some questions?!

#IDTwitter #IDMedED @ID_fellows

2/You are called by the ED for post-exposure ppx after sexual assault. What is your recommendation for a pt with severe type I allergy to cephalosporins?

CRO Ceftriaxone IM
AZM Azithromycin PO
MET Metronidazole PO
GENT Gentamicin IM
SPEC Spectinomycin IM
CIP Ciprofloxacin PO

3/ Answer was option 2 featuring gentamicin

Check out the options below

Won't cover HBV PEP recs for this tweetorial today!

4/ Next Q:
22yo cisgender woman presents for HIV PEP. No medical conditions, no home meds. What do you recommend?

TDF, tenofovir disoproxil fumarate
TAF, tenofovir alafenamide

5/
CDC guidelines recommend #1 or #2. Check out this chart on the preferred options

No major studies with TAF for PEP. Alternatives are listed below. Options such as Darunavir/r are available, but RAL/DOL prob better tolerated

Link to CDC guidelines: https://www.cdc.gov/hiv/pdf/programresources/cdc-hiv-npep-guidelines.pdf

5/CDC guidelines recommend #1 or #2. Check out this chart on the preferred options No major studies with TAF for PEP. Alternatives are listed below. Options such as Darunavir/r are available, but RAL/DOL prob better toleratedLink to CDC guidelines: https://www.cdc.gov/hiv/pdf/programresources/cdc-hiv-npep-guidelines.pdf

6/
Have you ever wondered about biktarvy for PEP? Prelim results of a safety/tolerability study at Fenway Health looking at TAF as PrEP were reported at CROI 2020 @khmayer1

https://www.croiconference.org/abstract/safety-and-tolerability-of-once-daily-bic-ftc-taf-for-postexposure-prophylaxis/

7/ Now onto HIV PrEP!
35yo cisgender MSM pt with 10 partners, rectal GC in the past 12m. Wants PrEP. No renal dz, hep B, sxs. You order HIV Ab/Ag, hep B/C serologies, Cr.

When do you start PrEP?

8/
Start that day!
Check out the poster and webcast for this study on immediate PrEP. Safe to rx now, d/c if labs abnl - the potential loss to f/u was substantial: https://www.croiconference.org/abstract/immediate-prep-initiation-new-york-city-sexual-health-clinics/

9/
A paper that must be covered in any PrEP discussion: DISCOVER, which shows non-inferiority of FTC/TAF to FTC/TAF with slight different in side effect profile https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31065-5/fulltext?rss=yes
@khmayer1

10/
Read more about TAF in PrEP from @douglaskrakower in this paper! https://pubmed.ncbi.nlm.nih.gov/31931525/

Another key point: transgender populations are relatively invisible in these PrEP studies. Here is a commentary from Doug in CID on this topic:
https://pubmed.ncbi.nlm.nih.gov/32766887/

11/
A quick reference for on-demand PrEP, "2-1-1"

Link to Ipergay study: https://www.nejm.org/doi/full/10.1056/nejmoa1506273

12/ Last Q:
28y cisgender woman has HIV+ cisgender male partner. He uses ART with undetectable VL. Sex 2x/wk. Do not want to use condoms. Your counseling about HIV transmission is that studies suggest that risk of HIV transmission is