Managing a High-Risk, Young Patient
AUTHOR:
Diana Finkel, DO
Assistant Professor of Medicine
Program Director, Infectious Diseases Fellowship Program
Rutgers New Jersey Medical School
Newark, New Jersey
CITATION:
Finkel D. Test your knowledge of HIV: managing a high-risk, young patient. Consultant360. Published online August 2, 2021.
A 19-year-old man presents to your clinic for an annual influenza vaccination and routine check-up before returning to college for the fall semester.
During the history-taking process, the patient says he is happy to be independent in college and has become sexually active recently. He has had several male partners since he saw you last. He also reports potentially being exposed to syphilis one month prior to his visit. He had presented to the campus health department at that time, during which visit he was tested for syphilis. Results were negative, but he had received preemptive treatment anyway.
At his current visit, the patient is asymptomatic. However, knowing that being exposed to one sexually transmitted infection (STI) raises the risk of exposure to other STIs like HIV, you consult the Centers for Disease Control and Prevention’s guidelines on STIs, which were updated recently. You decide to conduct a 3-part STI test (ie, oral, genital, rectal) and a rapid HIV test, results of which are negative.
Answer and discussion on next page.
Correct Answer: E. Both A and B
The presented patient is at increased risk of HIV infection because (1) he is a man who has sex with men (2) he has had multiple sex partners in the recent past, and (3) he may or may not know the HIV status of his partners.1 Therefore, Answer C is incorrect. Medication should be prescribed first, and then a follow-up visit should be scheduled. Follow-up visits should be scheduled every 3 months to assess HIV status, any adverse effects of the medication, medication adherence, STI symptoms, and HIV risk behaviors.2
Answer D is also incorrect, because the patient’s test results were negative. Had his results been positive, referral to an HIV care specialist would be warranted.3 However, PrEP can be managed in a primary care, family medicine, or internal medicine setting. The medications are simple, and follow-up testing does not require a specialist. Moreover, new legislation makes PrEP free to all qualifying patients under most insurances, so there are no special billing codes or procedures.4
The updated guidelines1 recommend first checking the HIV status of your patient via rapid combined Ag/Ab or antibody blood tests, then initiate PrEP without delay. In the presented patient, the results of his HIV test were negative. Therefore, PrEP should be prescribed. Currently, 1 PrEP medication and its generic form are approved by the US Food and Drug Administration.5 Emtricitabine/tenofovir (Descovy and Truvada) is indicated for adults and adolescents who weigh at least 35 kg.
As with all sexually active adolescents or adults who are at an increased risk for STIs, the presented patient should also be counselled about safe-sex practices, including the importance of using contraception such as condoms.6
References
1. Sexually transmitted infections treatment guidelines, 2021. Centers for Disease Control and Prevention. Updated July 22, 2021. Accessed July 29, 2021. https://www.cdc.gov/std/treatment-guidelines/toc.htm
2. Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 Update: clinical providers’ supplement. Centers for Disease Control and Prevention: US Public Health Service. Published March 2018. Accessed July 29, 2021. https://www.cdc.gov/hiv/pdf/risk/prep-cdc-hiv-prep-provider-supplement-2017.pdf
3. HIV infection: detection, counseling, and referral. Sexually transmitted infections treatment guidelines, 2021. Centers for Disease Control and Prevention. Updated July 22, 2021. Accessed July 29, 2021. https://www.cdc.gov/std/treatment-guidelines/hiv.htm
4. PrEP Access and Coverage Act, HR 3815, 116 Cong (2019-2020). Accessed July 29, 2021. https://www.congress.gov/bill/116th-congress/house-bill/3815/text
5. FDA approves second drug to prevent HIV infection as part of ongoing efforts to end the HIV epidemic. News release. US Food and Drug Administration. October 3, 2019. Accessed July 29, 2021. https://www.fda.gov/news-events/press-announcements/fda-approves-second-drug-prevent-hiv-infection-part-ongoing-efforts-end-hiv-epidemic
6. Behavioral counseling interventions to prevent sexually transmitted infections: recommendation statement. Am Fam Physician. Published online April 1, 2015. https://www.aafp.org/afp/2015/0401/od2.html