1 00:00:08,060 --> 00:00:12,809 Sara Dong: Hi everyone, welcome to Febrile, a cultured podcast about all things infectious disease. 2 00:00:13,119 --> 00:00:18,200 We use consult questions to dive into ID clinical reasoning, diagnostics, and antimicrobial management. 3 00:00:18,589 --> 00:00:21,340 I'm Sara Dong, your host and a MedPedsID doc. 4 00:00:21,810 --> 00:00:24,520 Today, I have two guests from the University of Toronto. 5 00:00:24,660 --> 00:00:25,680 First up is Dr. 6 00:00:25,680 --> 00:00:26,899 Maxime Billick. 7 00:00:26,900 --> 00:00:28,653 Maxime Billick: Hi, I'm Maxime. 8 00:00:28,653 --> 00:00:34,690 I'm a newly graduated ID, I guess, staff, former fellow from the University of Toronto. 9 00:00:35,080 --> 00:00:43,870 Sara Dong: Maxime is a recent graduate of the ID program at the University of Toronto, where much of her resident research centered around post-exposure prophylaxis in pocket. 10 00:00:44,450 --> 00:00:48,390 She is excited to start her master in public health this academic year at the T. 11 00:00:48,390 --> 00:00:48,560 H. 12 00:00:48,570 --> 00:00:51,110 Chan School of Public Health at Harvard University. 13 00:00:51,490 --> 00:00:52,640 Isaac Bogoch: Hey, I'm Isaac Bogoch. 14 00:00:52,710 --> 00:00:57,640 I'm an infectious diseases physician and scientist based out of the Toronto General Hospital and the University of Toronto. 15 00:00:57,740 --> 00:00:58,030 Sara Dong: Dr. 16 00:00:58,050 --> 00:01:01,860 Isaac Bogoch is an associate professor at the University of Toronto and an I. 17 00:01:01,860 --> 00:01:02,040 D. 18 00:01:02,040 --> 00:01:04,090 specialist at Toronto General Hospital. 19 00:01:04,340 --> 00:01:07,890 He focuses on tropical diseases, HIV, and general I. 20 00:01:07,890 --> 00:01:08,310 D. 21 00:01:08,710 --> 00:01:17,930 He works at the intersection of clinical medicine, epidemiology, public health, and policy, and he divides his clinical and research efforts between Toronto and several countries in Africa and Asia. 22 00:01:18,100 --> 00:01:27,410 His work focuses on integrating HIV prevention strategies for marginalized communities and mitigating the impact of emerging infectious diseases such as COVID and impacts. 23 00:01:27,705 --> 00:01:36,155 As everyone's favorite cultured podcast, I would love to hear, you know, a little piece of culture, something non medical that brings you happiness. 24 00:01:37,274 --> 00:01:37,524 Maxime Billick: Sure. 25 00:01:37,524 --> 00:01:52,565 I've been thinking about this for a while cause I listened to your podcast and I don't know if I'll think of something as punchy as I wanted to, but, um, I'm about to go to Maine with my whole big family, like my brothers and their kids and my parents and my partner. 26 00:01:52,975 --> 00:02:03,479 And, uh, I used to go when I was a kid and, you know, we would catch crabs and play on the beach, and it's just really nice to be there as a big family and to see my nieces and nephews do that too. 27 00:02:03,910 --> 00:02:06,649 Um, so I'm psyched for that and to eat lots of lobster. 28 00:02:07,289 --> 00:02:10,169 Sara Dong: That sounds like an awesome summer day. 29 00:02:10,359 --> 00:02:11,059 Maxime Billick: It's a bit of a dream. 30 00:02:11,399 --> 00:02:11,749 Sara Dong: Yeah. 31 00:02:12,119 --> 00:02:13,049 What about you, Isaac? 32 00:02:13,900 --> 00:02:35,090 Isaac Bogoch: I'm a, I love traveling, but I've discovered being a tourist in my own city is wonderful and, uh, really looking at exploring different neighborhoods and aspects of Toronto from a tourist viewpoint and, uh, it's been a lot of fun doing that and I hope to continue doing that, uh, not just this summer but, uh, moving forward. 33 00:02:35,480 --> 00:02:36,029 Sara Dong: Excellent. 34 00:02:36,049 --> 00:02:38,559 Well, any particular recommendations? 35 00:02:38,570 --> 00:02:40,749 Say it's someone's first time in Toronto. 36 00:02:41,799 --> 00:02:52,900 Isaac Bogoch: There's like the obvious big things to see and do, but, you know, I'm totally biased here, but when you scratch the surface, it's a huge city. 37 00:02:53,049 --> 00:02:54,250 There's so much to do. 38 00:02:54,600 --> 00:02:58,030 The music scene is just unbelievable. 39 00:02:58,090 --> 00:03:07,670 And, uh, you know, there's obviously the big venue concerts, but these little venue, uh, shows in various parts of the city are just, are just remarkable. 40 00:03:08,130 --> 00:03:11,120 And it's one of the most multicultural cities on the planet. 41 00:03:11,130 --> 00:03:12,990 The food is unbelievable. 42 00:03:13,380 --> 00:03:27,260 And, um, you know, you can go to various nooks and crannies in the city and eat in, uh, hole in the wall restaurants and have, you know, not just Ethiopian food, but southwestern Ethiopian food or northeastern Ethiopian food. 43 00:03:27,320 --> 00:03:30,980 Like, it's just, the variety is, is unparalleled here. 44 00:03:30,990 --> 00:03:32,090 We're very lucky to live here. 45 00:03:32,090 --> 00:03:36,195 And I, I don't, I don't think we use our city as much or as well as we should. 46 00:03:36,195 --> 00:03:36,855 There's lots to do. 47 00:03:36,855 --> 00:03:40,265 And I'm having a lot of gratitude these days for living here. 48 00:03:41,075 --> 00:03:41,334 Sara Dong: Yeah. 49 00:03:41,335 --> 00:03:43,724 I was going to say, there's lots of good eats in Toronto. 50 00:03:43,725 --> 00:03:45,924 I've had a lot of great meals there. 51 00:03:46,094 --> 00:03:50,105 Alright, so today we're going to flip our usual structure slightly. 52 00:03:50,364 --> 00:03:57,194 We're going to talk more broadly about our topic first and then discuss a few almost rapid fire clinical scenarios towards the end. 53 00:03:57,194 --> 00:04:00,355 So our focus today is going to be on HIV prevention. 54 00:04:01,144 --> 00:04:05,454 Or more specifically PIP, which is post exposure prophylaxis in pocket. 55 00:04:05,515 --> 00:04:08,055 And we are going to be using these abbreviations or terms. 56 00:04:08,055 --> 00:04:15,075 So we're going to do our best to make sure we're defining the full name of what we mean when we're first using that abbreviation. 57 00:04:15,700 --> 00:04:25,250 So back in 2021, you know, when we started Febrile, we did have a brief, uh, HIV starter pack of episodes that we called Fresh StART. 58 00:04:25,510 --> 00:04:31,919 And we did speak a little bit about PrEP, but not really about PEP, post exposure prophylaxis or PIP. 59 00:04:32,239 --> 00:04:39,775 So I'm actually going to start with that, you know, start quite broad with the question, what is biomedical HIV prevention? 60 00:04:40,165 --> 00:04:44,034 What are the current types of options that we have in North America? 61 00:04:44,355 --> 00:04:46,145 So maybe I'll throw that to you, Maxime. 62 00:04:46,565 --> 00:04:47,015 Maxime Billick: Sure. 63 00:04:47,055 --> 00:04:47,364 Yeah. 64 00:04:47,364 --> 00:04:48,275 Thanks so much. 65 00:04:48,694 --> 00:04:56,054 So when we think about biomedical HIV prevention, what that usually means is using medicines to prevent HIV. 66 00:04:56,055 --> 00:04:59,015 Like we know that there's a lot of behavioral things that people can do. 67 00:04:59,335 --> 00:05:17,284 People can wear condoms, people can abstain, people can choose to partake in lower risk activities that don't have as high a risk of transmission, but the term biomedical HIV prevention really refers to somehow getting some sort of medicine in your system to prevent acquisition of HIV. 68 00:05:17,395 --> 00:05:28,804 The sort of mainstays of therapy for biomedical HIV prevention up until pretty recently was something called PrEP, you alluded to it, pre exposure HIV prophylaxis. 69 00:05:29,284 --> 00:05:39,075 Usually, this is a two drug regimen whereby people take a pill every day to prevent getting HIV when they do have a potential risk encounter. 70 00:05:39,815 --> 00:05:44,235 There's also something called on demand PrEP, or 2-1-1. 71 00:05:44,515 --> 00:05:57,324 So if like someone's going, I don't know, it's a Friday night, they know they're going out, they might hook up with someone, they can take two pills of PrEP two to 24 hours before, one pill the next day, and then one pill the day after. 72 00:05:57,655 --> 00:06:06,610 And the thought is that - well not really the thought - the evidence shows that that prevents against HIV, particularly in people who have penises or men. 73 00:06:07,260 --> 00:06:11,829 Pretty excitingly, there are some new drugs on the market, specifically injectables. 74 00:06:12,260 --> 00:06:23,499 So this is usually a one drug regimen and people get a shot, usually in the bum, and that is the up until like about a week ago, that was monthly. 75 00:06:23,659 --> 00:06:28,090 Although there's some new evidence for a drug called lenacapavir in women, which is really cool. 76 00:06:28,109 --> 00:06:30,840 It was just hot off the press this past Wednesday. 77 00:06:30,840 --> 00:06:31,140 Yeah. 78 00:06:31,140 --> 00:06:31,409 Yeah. 79 00:06:31,409 --> 00:06:36,409 So this was like really hot off the press, but let's just say, you know, an injectable at a longer interval. 80 00:06:37,800 --> 00:06:41,309 And then you guys, I believe in the States, correct me if I'm wrong. 81 00:06:41,309 --> 00:06:41,980 We're in Canada. 82 00:06:42,030 --> 00:06:45,540 So I think you have a ring that people with vaginas can wear. 83 00:06:45,790 --> 00:06:50,750 That's not really super prevalent here, um, in Canada, but that's an option. 84 00:06:50,770 --> 00:06:53,790 And then there's some research going on about, uh, implants. 85 00:06:54,030 --> 00:06:58,820 So like the same way that there's like Implanon and Nexplanon for prevention of getting pregnant. 86 00:06:59,219 --> 00:07:01,849 There's some research into that, but it's not actually out on the market yet. 87 00:07:02,620 --> 00:07:08,860 So all of those are versions of PrEP, or pre exposure prophylaxis, before the risk encounter occurs. 88 00:07:10,060 --> 00:07:13,790 Then there's something called PEP, or post exposure prophylaxis. 89 00:07:13,920 --> 00:07:28,620 And that is, someone has a risk exposure that can be sexual, that could be, um, sharing needles, et cetera, and they go to care and they take a three drug regimen for usually about 28 days. 90 00:07:29,090 --> 00:07:41,419 I think we're going to get into some of the benefits and limitations of these after, so I'm not going to jump into it just now, but I'll just say that usually people have to present to care after the fact, which can be a huge barrier to care. 91 00:07:41,950 --> 00:07:46,340 And, uh, they take it for 28 days and then they stop. 92 00:07:48,325 --> 00:07:55,625 And the newest kid on the block, which is, you know, a little bit more implementation focused is PIP or post exposure prophylaxis in pocket. 93 00:07:56,225 --> 00:08:01,804 And then maybe I'll save that for Isaac to explain a bit down the road. 94 00:08:02,584 --> 00:08:02,924 Sara Dong: Yeah. 95 00:08:02,935 --> 00:08:11,125 So, you know, I think a lot of people who listen to Febrile have at least some familiarity with PrEP, and/or are prescribing it frequently. 96 00:08:11,175 --> 00:08:25,214 We know it works extraordinarily well for people who are at risk for HIV, but before we throw it over to Isaac, maybe you can quickly summarize those barriers that we often encounter when thinking about PrEP or pre exposure prophylaxis. 97 00:08:26,055 --> 00:08:26,645 Maxime Billick: Totally. 98 00:08:26,795 --> 00:08:28,684 So PrEP is pretty great. 99 00:08:28,744 --> 00:08:32,805 It works really well for people who are at risk of HIV. 100 00:08:33,159 --> 00:08:42,640 But most of the research has been in gay and bisexual men who have sex with men, and that's where we've seen the really striking benefits up until recently. 101 00:08:43,400 --> 00:08:45,280 Some of the, like, there are multiple barriers. 102 00:08:46,830 --> 00:08:48,600 It's an expensive medication, right? 103 00:08:48,639 --> 00:08:55,114 So if people don't have coverage, if people have to pay out of pocket, it can be hundreds, if not thousands of dollars a month. 104 00:08:55,754 --> 00:08:59,624 Um, it's taking a pill per day, so people have to remember to take the pill. 105 00:08:59,764 --> 00:09:02,024 They have to take it around the same time every day. 106 00:09:02,274 --> 00:09:04,545 There's potential side effects to taking medications. 107 00:09:05,345 --> 00:09:11,165 The side effects are usually pretty minimal, but in some people, it's enough to stop taking the medication or to not want to take it at all. 108 00:09:11,275 --> 00:09:18,064 Importantly, the 2-1-1 regimen, or PrEP on demand, only has evidence in men who have sex with men. 109 00:09:18,814 --> 00:09:22,785 So we don't know if it gets into vaginal tissue as quickly or as well. 110 00:09:23,685 --> 00:09:28,275 Also, in all of the studies, people were taking it like upwards of four times a month. 111 00:09:28,425 --> 00:09:34,154 So they're taking pills in their system, four times three is at least 12 days out of a month, right? 112 00:09:34,154 --> 00:09:35,444 About one third of the time. 113 00:09:36,124 --> 00:09:41,075 We don't know how well it works for people who are having four encounters per year, right? 114 00:09:41,095 --> 00:09:44,275 Like, are the levels in tissues as high? 115 00:09:44,505 --> 00:09:45,285 We have no idea. 116 00:09:46,175 --> 00:09:56,334 And so those are some of the biggest barriers, I think, to PrEP, you know, not to mention that you have to usually, you know, go see a doctor pretty frequently, usually every three months. 117 00:09:56,725 --> 00:10:05,084 Um, there are some online options now, but it, you know, you still have to have access to the internet or to a computer or to a safe space to have these conversations. 118 00:10:06,005 --> 00:10:10,844 Um, so I, I think that those are, some of the main limitations of PrEP. 119 00:10:11,885 --> 00:10:12,235 Sara Dong: Great. 120 00:10:12,275 --> 00:10:12,505 Yeah. 121 00:10:12,505 --> 00:10:14,324 So that's our PrEP bucket. 122 00:10:14,805 --> 00:10:19,935 And now thinking about PEP, which has also had success, a lot of data out there. 123 00:10:20,455 --> 00:10:25,775 Maxime started to refer to one of the big barriers of PEP, which is actually presenting to care. 124 00:10:26,564 --> 00:10:35,435 Isaac, what are other things that you think about as far as limitations of, uh, what we could kind of call traditional PEP or post exposure prophylaxis? 125 00:10:36,265 --> 00:10:36,665 Isaac Bogoch: Yeah. 126 00:10:36,724 --> 00:10:38,214 Thanks for bringing that up, uh, Sara. 127 00:10:38,224 --> 00:10:39,234 It's a good point. 128 00:10:39,599 --> 00:10:41,050 And PEP is phenomenal. 129 00:10:41,199 --> 00:10:42,400 It works really, really well. 130 00:10:42,410 --> 00:10:59,569 We have decades of experience with it, but, you know, there are, it's not, for something that works so well, I think if you talk to people who deal with HIV prevention pretty regularly, I think many people would be frustrated in implementation. 131 00:10:59,590 --> 00:11:03,189 And a lot of that is, uh, because of the, the, the barriers. 132 00:11:03,500 --> 00:11:07,699 A lot of these barriers are related to accessing care, right? 133 00:11:07,759 --> 00:11:09,030 First of all, the clock is ticking. 134 00:11:09,030 --> 00:11:17,275 For PEP to really work well, you've got to start those medications as soon as possible, preferably within 24 hours, but usually within a 72 hour window. 135 00:11:17,604 --> 00:11:21,475 That means people, A, have to recognize an exposure has occurred. 136 00:11:21,814 --> 00:11:24,504 Some people might not, due to a variety of reasons. 137 00:11:24,914 --> 00:11:30,014 B, you have to have access to medical care, usually an emergency department or an urgent care clinic. 138 00:11:30,164 --> 00:11:36,265 And, again, we're thinking globally and locally, there are significant barriers to access to care. 139 00:11:36,585 --> 00:11:40,635 C, once you, let's say you, you, you recognize there's exposure and you make it to care. 140 00:11:40,815 --> 00:11:41,715 Well, now you're in care. 141 00:11:42,384 --> 00:11:49,055 First of all, you have to know that there's an option available to prevent HIV. 142 00:11:49,085 --> 00:11:53,204 So there's a community level awareness, which I think is significantly lacking. 143 00:11:53,635 --> 00:12:01,104 And then D, the clinicians, whoever's seeing you, has to know that there are pills that can work. 144 00:12:01,535 --> 00:12:06,585 And then E, you have to have access to those pills, and there's tremendous costs associated with them. 145 00:12:06,885 --> 00:12:11,345 So, there's a lot that goes into making PEP work well. 146 00:12:11,434 --> 00:12:13,875 Then on top of that, let's just think about a practical scenario. 147 00:12:14,744 --> 00:12:19,245 Someone has, uh, condomless anal sex. 148 00:12:19,514 --> 00:12:22,145 Some poor person is raped. 149 00:12:22,375 --> 00:12:26,075 Some person shares injection drug paraphernalia. 150 00:12:26,685 --> 00:12:45,955 You know, very few people want to go wait in an emergency department at four o'clock in the morning for four hours to talk to a total stranger in a crowded, busy place where everyone can hear about the rape they just survived, the anal sex they just had, or the needle they just stuck in their arm. 151 00:12:46,225 --> 00:12:53,490 So there's also, I think, that is an enormous to, uh, appropriate PEP rollout. 152 00:12:53,560 --> 00:13:03,419 Having said that, if people access the drugs, if they access it in a timely manner, if they take the medications, we just don't see HIV acquisition when, when PEP is used. 153 00:13:03,430 --> 00:13:10,455 So there are better ways to use PEP, which I think is a good segue into what we're going to talk about next. 154 00:13:10,785 --> 00:13:13,095 Sara Dong: Yeah, you're making my job pretty easy. 155 00:13:13,465 --> 00:13:16,905 So that's what we wanted to do is spend the bulk of this episode talking about PIP. 156 00:13:17,315 --> 00:13:25,605 You know, where that idea came from, how it's different from traditional post exposure prophylaxis and you know, a little bit on logistics of implementing this. 157 00:13:25,665 --> 00:13:27,534 So maybe I'll start there. 158 00:13:27,764 --> 00:13:30,985 What is PIP and how is it different from traditional PEP? 159 00:13:31,855 --> 00:13:37,725 Isaac Bogoch: Yeah, so PIP stands for PEP in pocket or post exposure prophylaxis in pocket. 160 00:13:37,725 --> 00:13:43,175 And really what this is, is an additional tool to prevent HIV. 161 00:13:43,185 --> 00:13:58,935 Really where we see this working best is for people who have anywhere from zero to four potential HIV exposures per year, so very infrequent exposures per year, and we proactively identify who these individuals are. 162 00:13:58,935 --> 00:14:09,884 These exposures may or may not be unexpected, and we proactively provide them with guideline approved post exposure prophylaxis regimen, the full 28 day course. 163 00:14:10,205 --> 00:14:22,905 We obviously are aware that guidelines differ in different parts of the world, that's why instead of saying use this drug or that drug, we just say guideline approved PEP regimens, and the important point is the full 28 days. 164 00:14:23,355 --> 00:14:27,744 Because an exposure hasn't yet occurred, we have a bit of a gift of time. 165 00:14:28,125 --> 00:14:35,575 And that means we can work with whatever local health or support networks are available to ensure people are able to access those 28 days. 166 00:14:35,575 --> 00:14:38,365 And then we basically say, hey, here's 28 days of pills. 167 00:14:38,835 --> 00:14:41,275 Put this in your sock drawer and let it be. 168 00:14:41,525 --> 00:14:42,234 And live your life. 169 00:14:42,414 --> 00:14:54,924 And you know, in the scenario where there's a potential HIV exposure, individuals do not have to go seek immediate care at an urgent care center or an emergency department. 170 00:14:55,845 --> 00:15:14,554 We treat adults like adults, they have the pills, they know exactly what to do, there's virtually zero barriers to this whatsoever, you just go to your sock drawer, start one pill once a day, usually we use a one pill daily regimen these days, you have the full 28 days, and we say listen, on a much less urgent basis, hopefully within the first week, but you 171 00:15:14,555 --> 00:15:23,720 know, on a much less urgent basis, come into the clinic, let's do some baseline screening tests, make sure everything's okay, let's have a quick chat, make sure everything's okay. 172 00:15:24,050 --> 00:15:34,939 But really, this proactive identification of people with very low frequency HIV exposures will have much more timely access to antiretroviral medications. 173 00:15:35,310 --> 00:15:44,990 And we basically alleviate any need to seek urgent medical care, which we know, as we just talked about, is a major, major barrier to care. 174 00:15:45,710 --> 00:15:46,050 Sara Dong: Yeah. 175 00:15:46,050 --> 00:15:58,980 And is there anything else from a, you know, logistical or barrier perspective that either of you want to mention or maybe things that you talk about when you meet patients and are counseling them for the first time? 176 00:15:59,099 --> 00:16:00,220 Isaac Bogoch: Yeah, absolutely. 177 00:16:00,589 --> 00:16:01,730 I'll let Maxime jump in there. 178 00:16:01,730 --> 00:16:09,620 I'd love to hear her thoughts, but you know, this was really started in about 20, late 2013, early 2014. 179 00:16:09,640 --> 00:16:19,975 So PrEP, was in its infancy, globally, and we actually started the first PrEP program in Canada at the Toronto General Hospital. 180 00:16:20,265 --> 00:16:44,490 And we were rolling out PrEP very early on, but, you know, between myself, a wonderful nurse, Pauline Murphy, and a very dedicated, wonderful social worker, Andrea Sharp, you know, we were clearly providing PrEP to people who were at high risk, but we didn't really have any good options for people at much lower risk, uh, who had much, sorry, much fewer frequency exposures. 181 00:16:44,990 --> 00:16:57,200 And that's where PIP was born, is putting a few heads together and finding creative solutions to basically what was a large vacuum in HIV prevention. 182 00:16:57,200 --> 00:17:13,490 We had good tools at that time, we continue to have wonderful and effective tools to prevent HIV and those with greater risk exposures, but there are a lot of people that, you know, probably shouldn't be taking one pill once a day, or an injectable, or even where 2 1 1 isn't, isn't appropriate, where 183 00:17:13,540 --> 00:17:22,760 PIP would really fit in, and, uh, and so we started implementing this and studying it way back in late 2013, early 2014, and it, it found a niche. 184 00:17:22,789 --> 00:17:29,975 Now again, is PIP going to you know, roll out globally and stop HIV, like absolutely not. 185 00:17:29,995 --> 00:17:39,615 It's just an additional tool and it provides more options available for patients and clinicians, uh, because we know people don't take a linear path through life. 186 00:17:39,615 --> 00:17:43,555 Their risk, their HIV risk is not linear through life. 187 00:17:43,555 --> 00:18:01,875 Some people are at very high risk for HIV and are appropriately on, on PrEP, but others, you know, maybe get into a stable monogamous relationship or something happens where they're no longer as high risk as they once were, but they still are not zero risk and PIP provides a really good tool to prevent HIV in those individuals. 188 00:18:01,925 --> 00:18:04,875 Maintains autonomy and agency over their care. 189 00:18:05,135 --> 00:18:08,524 Immediate access to antiretroviral medication should an exposure occur. 190 00:18:08,794 --> 00:18:11,504 Sort of like one of those, you know, in emergency break glass. 191 00:18:11,504 --> 00:18:12,845 Here's an option available for you. 192 00:18:14,215 --> 00:18:32,290 Maxime Billick: And then maybe just from a, um, like more, uh, detailed perspective, you know, in addition to prescribing people PIP and then asking them to give us a call and to come back to clinic, you know, a week or two later for testing, we do baseline testing, similar to how you would do 193 00:18:32,290 --> 00:18:42,409 baseline testing for PrEP, or in a situation like, you know, PEP in the emergency department, so, you know, we'll do a CBC, creatinine, liver enzymes. 194 00:18:42,899 --> 00:18:52,580 We screen for sexually transmitted infections, gonorrhea and chlamydia in the throat, rectum, anus, you know, depending on people's sexual practices or everything. 195 00:18:52,709 --> 00:18:53,919 I usually just do everything. 196 00:18:54,320 --> 00:18:59,310 Uh, syphilis serology, I don't You know, people can not always tell you everything. 197 00:18:59,670 --> 00:19:11,569 We, you know, routinely screen for HIV, and then we screen for hepatitis A, B, and C, and we ensure vaccination to A and B if they're non immune, and then don't forget doing some pregnancy testing. 198 00:19:11,629 --> 00:19:18,629 I don't always think of that as an internist, but it's always a good thing if you have people with uteruses coming to see you. 199 00:19:19,020 --> 00:19:26,865 And then, you know, if people have exposures and use their PIP, then we'll see them, you know, in short term interval follow up. 200 00:19:27,265 --> 00:19:35,174 Otherwise, we tend to see them about every six months just to do routine testing and to make sure that PIP is still right for them. 201 00:19:35,265 --> 00:19:41,215 So as Isaac mentioned, you know, people's risk changes throughout their lives and their circumstances. 202 00:19:41,745 --> 00:19:55,125 So, you know, if they're having a lot more, for example, sex or HIV risk encounters, and they found that they've actually used PIP three times in a row, then maybe it's no longer the best modality for them. 203 00:19:55,125 --> 00:19:57,945 And we can talk about switching to other modalities. 204 00:19:58,729 --> 00:19:59,070 Sara Dong: Yeah. 205 00:19:59,100 --> 00:20:05,510 So, you know, along those lines, when you're talking with patients, how do you make sure that PIP is the best modality for them? 206 00:20:05,899 --> 00:20:17,040 You started to talk a little bit about who, who might be the best candidates, but what are things that you may hear from a patient that tell you, maybe we should consider changing the method of HIV prevention that we're using? 207 00:20:17,769 --> 00:20:18,229 Maxime Billick: Totally. 208 00:20:18,279 --> 00:20:36,530 So if people are having more than 4 exposures or potential exposures per year, to us that says, you know, hey, maybe this isn't quite working for them because then they're taking, you know, post exposure prophylaxis, 3 drug regimen for about 4 months a year. 209 00:20:37,980 --> 00:20:41,190 At that point, a version of PrEP is probably more appropriate. 210 00:20:41,730 --> 00:20:46,979 If they're not tolerating the medications for whatever reason and we would need to potentially switch them. 211 00:20:47,250 --> 00:20:49,390 You know, also, of course, patient preference. 212 00:20:49,500 --> 00:20:56,860 So if they're like, you know what, it's, it makes me really anxious that I have a potential risk exposure. 213 00:20:56,860 --> 00:21:05,980 I know I'm not having many, but I just want to know that I'm totally protected all of the time, et cetera, et cetera, you know, then we'll have a conversation with them about that. 214 00:21:06,300 --> 00:21:12,700 So really like the point of of PIP is to just have another tool in your toolbox to offer patients. 215 00:21:13,170 --> 00:21:21,979 Um, and it's going to be an ongoing discussion and just the same way that we put a lot of other medications in the hands of patients. 216 00:21:22,440 --> 00:21:30,070 So, for example, people will have pill in pocket beta blockers for, you know, anxiety or for palpitations. 217 00:21:30,460 --> 00:21:36,560 I don't know about in the States, but in Canada, you can now get single dose fluconazole for vaginal yeast infections over the counter. 218 00:21:36,970 --> 00:21:41,429 Plan B in a lot of places is available, you know, with just a pharmacist consultation. 219 00:21:41,899 --> 00:21:46,680 So, you know, we trust patients to do that, to take those medications. 220 00:21:46,889 --> 00:21:53,089 I think that we can trust patients with enough education to take their PIP at an appropriate time. 221 00:21:53,090 --> 00:21:53,389 Isaac Bogoch: Yeah. 222 00:21:53,669 --> 00:21:54,020 Yeah. 223 00:21:54,425 --> 00:21:56,095 Uh, Maxime, I'm, I'm with you all the way. 224 00:21:56,095 --> 00:21:58,215 That's, that's so, so well said. 225 00:21:58,885 --> 00:22:02,655 I've been calling this the buffet approach to HIV prevention. 226 00:22:03,145 --> 00:22:05,084 And for starters, I love buffets. 227 00:22:08,254 --> 00:22:14,275 But secondly, you know, the buffet is really, here are all the options available. 228 00:22:14,474 --> 00:22:16,275 Here is everything that we have. 229 00:22:16,385 --> 00:22:29,685 We have injectable PrEP, we've got 2 1 1, we've got daily PrEP, we've got TAF FTC, we've got TDF FTC, we also have PIP, sort of in the middle, and at the lower end of the spectrum, we have nothing. 230 00:22:29,695 --> 00:22:31,054 You can choose to do nothing as well. 231 00:22:31,424 --> 00:22:37,684 And I think what we do very poorly in HIV prevention is reassess risk at every clinic appointment. 232 00:22:37,934 --> 00:22:43,664 And we should really be doing that with all of our patients at all of our clinical encounters is reassessing risk. 233 00:22:43,694 --> 00:22:44,794 Risk is not static. 234 00:22:44,794 --> 00:22:45,904 Of course, it's dynamic. 235 00:22:46,184 --> 00:22:56,810 And we have more tools in our toolbox to offer patients, and we can provide a much more granular approach to HIV prevention in 2024 compared to prior years. 236 00:22:56,820 --> 00:22:57,889 So it's remarkable. 237 00:22:57,889 --> 00:23:06,089 And, and as you guys were chatting about earlier, like the, uh, the further options with injectables are coming through the pipeline, this is a really exciting time. 238 00:23:06,649 --> 00:23:24,999 So, you know, every time someone comes in, you know, obviously we, we, we talk about, you know, how's it going, drug effects, uh, you know, tolerance, et cetera, screening, but, but I think it's extremely important to talk about, are you on the right drug? 239 00:23:25,490 --> 00:23:31,190 or the right program for now and for your near future. 240 00:23:31,689 --> 00:23:36,379 And most of the time the answer is yes, and we just carry on carrying on with with PrEP or whatever someone is on. 241 00:23:36,489 --> 00:23:37,969 But a lot of the time the answer is no. 242 00:23:38,169 --> 00:23:39,570 And again, this is the buffet. 243 00:23:39,659 --> 00:23:41,429 Here are all the options available. 244 00:23:41,570 --> 00:23:43,329 You're always welcome back to the table. 245 00:23:43,350 --> 00:23:44,600 You can take whatever you want. 246 00:23:45,029 --> 00:23:47,898 Uh, let's have an evidence based, patient centered approach. 247 00:23:47,898 --> 00:23:52,459 Let's listen, as I love how Maxime pointed out, listen to patient preference as well. 248 00:23:52,459 --> 00:24:01,154 That drives a lot of this, but we can enable smart decision making by giving people the options, letting people know what the options are available, and then supporting them in their choice. 249 00:24:01,154 --> 00:24:04,674 And the other important thing to do is to remind people no decision is set in stone. 250 00:24:05,085 --> 00:24:06,695 Of course, we tell people flat out. 251 00:24:06,705 --> 00:24:09,184 Of course, risk is dynamic. 252 00:24:09,524 --> 00:24:11,124 You might be on PrEP for a little while. 253 00:24:11,124 --> 00:24:13,189 If you ever want to change to PIP, come on in. 254 00:24:13,199 --> 00:24:13,810 No problem. 255 00:24:13,840 --> 00:24:21,220 Happy to, happy to put you on PIP if you're on PIP and you're having more frequent exposures or you might be anticipating having more frequent exposures. 256 00:24:21,409 --> 00:24:22,490 Let's move you back to PrEP. 257 00:24:22,710 --> 00:24:31,154 And in fact, in some of the research that we've been publishing over the last few years shows, you know, about a third of our patients on PREP have moved to PIP at some point in their life. 258 00:24:31,735 --> 00:24:36,344 Life, a third of our patients on PrEP, on PIP, have transitioned to PrEP at some point. 259 00:24:36,344 --> 00:24:41,155 So there, it's, it's really helpful to have these, these tools available. 260 00:24:41,405 --> 00:25:00,390 And one other key point, you know, the WHO just released their HIV prevention, their post exposure prophylaxis guidelines, literally this month, July of 2024 at the IAS conference in Munich, and they've integrated PEP in pocket into those guidelines, which is pretty remarkable. 261 00:25:00,390 --> 00:25:06,370 And they, they talk about how, uh, PIP might be a useful tool for, for some people. 262 00:25:06,370 --> 00:25:08,599 And these are exactly the scenarios that we're discussing. 263 00:25:08,619 --> 00:25:18,230 So I think we're going to start to see this roll out much more broadly given its international exposure and integration into WHO post exposure prophylaxis guidelines. 264 00:25:18,230 --> 00:25:20,420 And exactly like Maxime said, it's. 265 00:25:20,640 --> 00:25:22,130 It's another tool in the toolbox. 266 00:25:22,170 --> 00:25:23,960 It gives more options to patients. 267 00:25:23,960 --> 00:25:27,640 It gives more options to providers to offer their patients. 268 00:25:28,010 --> 00:25:35,330 And I think it really helps for people who have a dynamic risk or even people have a static low frequency risk as well. 269 00:25:35,859 --> 00:25:36,169 Sara Dong: Yeah. 270 00:25:36,169 --> 00:25:40,790 And so we're going to move into some of those clinical scenarios in just a second about picking from the buffet. 271 00:25:41,129 --> 00:25:47,359 But one last thing before that is how do you switch people from PIP to PrEP and vice versa? 272 00:25:48,090 --> 00:25:48,340 Maxime Billick: Sure. 273 00:25:48,370 --> 00:25:48,530 Yeah. 274 00:25:49,590 --> 00:25:50,110 So. 275 00:25:50,600 --> 00:25:52,500 Let's talk about PIP to PrEP first. 276 00:25:53,030 --> 00:26:03,270 If you're going from PIP to PrEP, you would do it, you know, if people are familiar with transitioning anyone from post exposure prophylaxis to PrEP, it's essentially the same. 277 00:26:03,270 --> 00:26:15,180 So you want to, you want your patient to continue and to complete their full 28 day post exposure prophylaxis or PEP course, um, you're going to do repeat testing, right? 278 00:26:15,389 --> 00:26:20,310 Make sure that they didn't acquire HIV at the end of the, at the end of the course. 279 00:26:20,709 --> 00:26:23,360 And then you're going to have them start PrEP right away. 280 00:26:23,990 --> 00:26:30,009 So, and that would be switching from a three drug regimen usually to a two drug regimen usually. 281 00:26:30,580 --> 00:26:34,990 Um, and then they would just continue on PrEP, you know, as, as one does. 282 00:26:35,889 --> 00:26:42,040 Going the other way around, you know, you can kind of switch or stop at any time. 283 00:26:42,090 --> 00:26:49,319 So, if someone's on PrEP and they feel like they don't really need it anymore, they're not having any high risk encounters, they can just stop cold turkey. 284 00:26:49,319 --> 00:26:54,150 And again, it's important to tell people usually to stop and not sort of take intermittently. 285 00:26:54,629 --> 00:27:02,600 And then when they do have a potential risk exposure, um, to start their PIP, you know, as soon as possible and within 72 hours. 286 00:27:03,455 --> 00:27:07,765 So again, pretty simple, um, the follow ups will obviously be a little bit different. 287 00:27:07,785 --> 00:27:17,645 Usually PrEP follow up is about every three, maybe every four months, whereas PIP follow up, if people are not using their PIP, then it's just every six months. 288 00:27:17,805 --> 00:27:22,415 If they do use their PIP, then, you know, we tell them to come in within a week or two of using it. 289 00:27:22,905 --> 00:27:23,415 Sara Dong: All right. 290 00:27:23,445 --> 00:27:23,765 Okay. 291 00:27:23,765 --> 00:27:26,365 So we're going to talk through a few clinical scenarios. 292 00:27:26,415 --> 00:27:27,315 I'll go back and forth. 293 00:27:27,315 --> 00:27:28,515 I'm going to start with you, Maxime. 294 00:27:28,555 --> 00:27:31,095 These will be just quick, you know, one to two liners. 295 00:27:31,115 --> 00:27:38,095 And then you can share with us what your thought process is for picking which item from the HIV prevention buffet. 296 00:27:40,555 --> 00:27:40,925 All right. 297 00:27:41,494 --> 00:27:43,795 So first we have a 25 year old male. 298 00:27:44,075 --> 00:27:52,955 He is a man who has sex with men, goes out about two weekends per month, and often has both receptive and penetrative anal sex with people he does not know. 299 00:27:53,575 --> 00:27:57,095 What is the best biomedical HIV prevention modality for him? 300 00:27:57,745 --> 00:27:58,284 Maxime Billick: Sure. 301 00:27:58,395 --> 00:28:01,495 So just picking out some key points here. 302 00:28:01,544 --> 00:28:13,095 So, you know, younger man, MSM, having some higher risk encounters, particularly with the receptive anal sex, going out, hooking up with people about two times per month. 303 00:28:13,415 --> 00:28:17,264 Um, so that is definitely more than four times per year. 304 00:28:17,645 --> 00:28:25,515 Um, so PIP actually isn't appropriate here just based on his frequency of encounters, and I would encourage him to use, um, PrEP. 305 00:28:26,824 --> 00:28:30,794 There are multiple different types of PrEP that would be appropriate in this case. 306 00:28:30,824 --> 00:28:39,524 So, again, he's going out pretty frequently, so daily PrEP, I think, would be something that I would try and advocate for, or if he's open to it, injectable PrEP. 307 00:28:39,895 --> 00:28:42,814 Um, some of that will depend on how often he wants to come in. 308 00:28:43,100 --> 00:28:48,550 If he likes to take, you know, he's okay with taking pills versus prefers injections, etc. 309 00:28:48,550 --> 00:28:54,439 2 1 1 or on demand PrEP could also be appropriate here. 310 00:28:54,929 --> 00:28:59,699 He's having lots of encounters, so I might try and, you know, see if he's open to the daily PrEP. 311 00:28:59,719 --> 00:29:05,759 But again, if he can't or if it's too expensive or whatnot, 2 1 1 would certainly be appropriate as well. 312 00:29:06,780 --> 00:29:07,540 Sara Dong: Excellent. 313 00:29:07,679 --> 00:29:09,510 Okay, Isaac, you're up for the next one. 314 00:29:10,479 --> 00:29:10,860 Isaac Bogoch: Sounds good. 315 00:29:10,995 --> 00:29:17,935 Sara Dong: A 36 year old woman who engages in sex work presents to a sexual health clinic for symptoms of a sexually transmitted infection. 316 00:29:18,945 --> 00:29:26,995 She routinely uses condoms, but says that this infection was acquired in the context of a non consensual, condomless sexual activity at work. 317 00:29:27,445 --> 00:29:28,685 What are you thinking about here? 318 00:29:29,404 --> 00:29:32,354 Isaac Bogoch: Yeah, just taking a step back, obviously this is an awful scenario. 319 00:29:32,544 --> 00:29:57,040 I know we're talking about HIV prevention, but you know, we still have to recognize this as a sexual assault and you would want to use every resource available to ensure psychosocial and other medical support for, for this poor individual, and, you know, honing down into the weeds and just focusing on HIV prevention, which, of course, is one important piece of a much larger puzzle. 320 00:29:57,409 --> 00:30:25,280 You know, I think this is, this is a scenario where you would really discuss with her, what her preferences are, and, you know, as we chatted about the buffet approach, you know, if this is someone who is truly only having a 0, 1, 2, or 3, or 4 exposures, potential exposures to HIV per year, meaning condoms are used appropriately and, and, um, consistently, both as part of sex work 321 00:30:25,300 --> 00:30:40,864 and out of sex work, then, you know, Uh, PIP may be a very reasonable option for, for her, as in, here's a wonderful and guideline approved approach to significantly reduce the risk of, of HIV. 322 00:30:40,874 --> 00:30:52,450 She would not have to go into an urgent care center, a sexual assault center, an emergency department to initiate, rapidly initiate antiretroviral therapy to prevent HIV infection. 323 00:30:52,450 --> 00:31:00,370 She could self initiate it as soon as possible and usually, easily within a 24 hour window should she have access to those medications like PIP provide. 324 00:31:00,800 --> 00:31:03,149 So I think PIP could be a good option. 325 00:31:03,400 --> 00:31:15,062 But again, like, like Maxime was saying earlier, some of, we can help walk people through various scenarios and enable and edu enable them to make smart decisions for themselves. 326 00:31:15,062 --> 00:31:24,984 If this is an individual who said, you know what, I'd just be more comfortable on PrEP, I'm not the gatekeeper to the healthcare system and I would certainly support her in that decision as well. 327 00:31:25,625 --> 00:31:30,124 And discuss the various merits and drawbacks and various types of PrEP for her preference. 328 00:31:30,125 --> 00:31:36,675 But certainly, this is an individual where PIP could, could, would be discussed and presented as an option. 329 00:31:36,704 --> 00:31:52,055 And, you know, quite frankly, we do follow people in our clinic who sadly have been in this very, uh, this exact scenario who are on PIP and who like it because it gives them immediate access to HIV prevention should they need it. 330 00:31:52,095 --> 00:32:06,065 And then, you know, God forbid a situation like this happens, they can also seek care with a provider that they're comfortable with and they don't have that urgency of seeking care within a 72 hour window because their HIV prevention has been initiated. 331 00:32:06,945 --> 00:32:07,245 Sara Dong: Thanks. 332 00:32:07,655 --> 00:32:08,165 All right. 333 00:32:08,584 --> 00:32:09,955 Bringing it back to you, Maxime. 334 00:32:10,710 --> 00:32:18,610 A 47 year old man taking HIV pre exposure prophylaxis, or PrEP, presents to a primary care clinic for a routine follow up visit. 335 00:32:18,690 --> 00:32:26,360 He is considering entering a monogamous relationship with a male partner, but is uncertain if he may have very infrequent sex with other partners. 336 00:32:26,609 --> 00:32:29,020 He's wondering about whether to discontinue PrEP. 337 00:32:29,460 --> 00:32:31,580 What type of conversation would you guys be having? 338 00:32:32,470 --> 00:32:32,810 Maxime Billick: Yeah. 339 00:32:32,820 --> 00:32:33,550 Thank you. 340 00:32:33,730 --> 00:32:37,980 So this is actually a scenario that we see not infrequently, right? 341 00:32:38,040 --> 00:32:45,379 As we've said multiple times throughout this chat, like, people's risk is dynamic and changes. 342 00:32:45,390 --> 00:32:56,580 And sometimes, like, we don't always know in advance what a future relationship is going to look like and when people are going to, you know, open it up to having sex with other partners or not. 343 00:32:56,930 --> 00:33:07,825 And so, what I hear in this situation is someone who is, you know, thinking about being or is currently being more monogamous, but there are the potential for risks in the future. 344 00:33:07,825 --> 00:33:12,164 And they seem a little bit nervous, perhaps like that they want to protect themselves. 345 00:33:12,905 --> 00:33:24,065 So, you know, a couple of things here is, oftentimes when I'm in these types of situations, I'll, again, explain the buffet of options that we have to patients and see if something sort of lands with them. 346 00:33:24,445 --> 00:33:30,744 Because the truth of the matter is that people don't always tell us as clinicians or as providers how much sex they're having. 347 00:33:30,985 --> 00:33:44,944 So if somebody If someone wants to continue on PrEP, maybe not this guy, but if someone wants to continue on PrEP, or they think it's right for them, you know, then it's my job to help facilitate that, not necessarily to ask, um, all of the details of their sex life, right? 348 00:33:45,635 --> 00:33:59,640 In this particular situation, you know, it sounds like, I think this patient is likely going to have very infrequent sex with other partners, and I think that PIP is a reasonable option, so I'd certainly offer that. 349 00:34:00,390 --> 00:34:03,780 Another potential one is 2 1 1 or PrEP on demand. 350 00:34:04,450 --> 00:34:08,340 It really depends if it's the type of thing that he is going to anticipate in advance. 351 00:34:08,629 --> 00:34:21,740 You know, is it like Okay, around pride or twice a year, like we're going to go to the bathhouse and I know that I'm going there and that's sort of the purpose or is it like, oh, it's going to happen more randomly and I'm not sure when it will happen. 352 00:34:22,040 --> 00:34:25,680 And so in those cases, PIP is more, um, appropriate, I think. 353 00:34:26,580 --> 00:34:27,130 Sara Dong: All right. 354 00:34:27,149 --> 00:34:28,600 And Isaac, you're going to round us out. 355 00:34:28,600 --> 00:34:29,790 This is our last one. 356 00:34:30,020 --> 00:34:30,380 Isaac Bogoch: Uh oh. 357 00:34:31,390 --> 00:34:31,990 Maxime Billick: Home run. 358 00:34:33,320 --> 00:34:33,720 Sara Dong: All right. 359 00:34:33,750 --> 00:34:39,379 So we have a 50 year old heterosexual woman who is traveling to South America on a three week trip. 360 00:34:39,900 --> 00:34:41,540 She might have sex while she's traveling. 361 00:34:41,859 --> 00:34:46,300 She usually wears condoms, but has had instances when intoxicated when she hasn't. 362 00:34:46,949 --> 00:34:50,349 She doesn't want to have to go to a local hospital or health clinic to get PEP. 363 00:34:51,009 --> 00:34:54,960 In fact, she tells you she probably just wouldn't and would ignore things until she got home. 364 00:34:55,410 --> 00:34:58,290 So what recommendations and counseling do you have for her? 365 00:34:59,135 --> 00:35:02,745 Isaac Bogoch: Yeah, Sara, this is like the underhand pitch right over the plate, right? 366 00:35:02,765 --> 00:35:12,765 Like, so here's someone who probably won't have an exposure to HIV because she uses condoms regularly, but oops, once in a while she does. 367 00:35:13,005 --> 00:35:14,434 Like, this is a no brainer. 368 00:35:14,475 --> 00:35:19,385 You give this person 28 days of a guideline approved PEP regimen to take with her on her trip. 369 00:35:19,675 --> 00:35:21,855 If she needs them, great. 370 00:35:21,885 --> 00:35:23,385 She's got immediate access to them. 371 00:35:23,385 --> 00:35:25,045 If she doesn't need them, great. 372 00:35:25,065 --> 00:35:33,850 They sit in her bag and, uh, and maybe she takes them on her next trip, you know, uh, but, uh, this is, this is a good scenario. 373 00:35:34,070 --> 00:35:37,045 Here's another potential scenario as well. 374 00:35:37,375 --> 00:35:43,075 Let's talk about people who work in our field, clinicians, who do work overseas as well. 375 00:35:43,295 --> 00:35:54,375 And they may have an occupational exposure or a non occupational exposure and require PEP, while they're working in a part of the world where there's limited access to healthcare. 376 00:35:54,395 --> 00:36:01,914 This is, this has been done in the past, mostly for occupational exposures, but we're really moving this into the non occupational exposure realm. 377 00:36:02,250 --> 00:36:04,300 And, uh, and have some significant success. 378 00:36:04,700 --> 00:36:15,420 Usually, you know, depending on where you are in the world, Biktarvy is the drug of choice, safe, one pill once a day, pretty, pretty widely available in many, of course, not in all places. 379 00:36:15,720 --> 00:36:18,330 Obviously, I appreciate there's different guidelines elsewhere. 380 00:36:18,469 --> 00:36:27,165 Some places are using, you know, You know, dolutegravir based regimens for uh, women who may be pregnant in the in the near future or are currently pregnant. 381 00:36:27,195 --> 00:36:30,235 Others are using Biktarvy in these scenarios as well. 382 00:36:30,295 --> 00:36:36,515 So again, I think the best way to frame it is whatever your local guidelines suggest are the drugs that that you should be sticking with. 383 00:36:36,784 --> 00:36:47,315 But the key is the full 28 days are provided so that people have truly few to no barriers to initiating antiretroviral medications should an exposure occur. 384 00:36:48,075 --> 00:36:52,375 Sara Dong: Thank you both so much for joining today and, um, tackling this topic. 385 00:36:52,455 --> 00:37:00,304 I'll open it up here since we're wrapping up to just see if there's any take home points or items that you want to reinforce for our listeners. 386 00:37:01,055 --> 00:37:04,085 Maxime Billick: Maybe I'll go first and then let Isaac, you know, close it out. 387 00:37:04,855 --> 00:37:24,875 We've probably sort of hammered this home multiple times, but really making sure that people understand that PIP is one option of many, and that a lot of this ends up being relationship building with the patient in front of you, seeing what is best for their current situation, for their potential future situation. 388 00:37:25,240 --> 00:37:29,720 And recognizing that this applies to a lot of different types of patients, right? 389 00:37:29,770 --> 00:37:34,290 It applies to the person who's traveling abroad twice a year. 390 00:37:34,420 --> 00:37:45,720 It applies to the person who was, you know, on PrEP and used to be having a lot of sex and now is in a monogamous relationship, but might have infrequent sex with another partner. 391 00:37:46,040 --> 00:38:10,959 It can apply to rural populations and people who have limited access to hospitals or no urgent care centers open in the middle of the night, um, so it really applies to different types of people and patients, and I would just encourage anyone listening to this podcast to think about, you know, the patients they serve and how this might sort of fit into their lives and their prevention strategy. 392 00:38:11,509 --> 00:38:14,280 Isaac Bogoch: Mine is, uh, pretty straightforward. 393 00:38:15,040 --> 00:38:19,910 I, you know, I think largely HIV prevention strategies have been ruled out. 394 00:38:20,575 --> 00:38:24,075 Pretty, pretty well, pretty effectively in many parts of the world. 395 00:38:24,105 --> 00:38:25,555 Obviously, there's room for improvement. 396 00:38:25,865 --> 00:38:42,975 I think one of the big areas we can do better in is constantly re evaluating the current and near future HIV risk of our patients, and we do that by talking to them and asking them, you know, what is your current and near future risk? 397 00:38:43,295 --> 00:38:44,755 And how many exposures are you having? 398 00:38:45,155 --> 00:38:48,185 And I think sometimes people just get stuck on, on PrEP. 399 00:38:48,590 --> 00:39:00,165 And, and most of those people still probably should be on PrEP, but there are certainly many who who shouldn't be on PrEP, where there's another HIV prevention modality like PIP, which would be better suited. 400 00:39:00,455 --> 00:39:12,584 And, and just appreciating the dynamic nature of risk, and now having more tools available to have the most appropriate HIV prevention modality for the, for the, for the patient that's, that we're trying to serve. 401 00:39:12,780 --> 00:39:22,100 I do like that concept of the buffet because everyone likes buffets and we have more options on the buffet and you can always come back to the table and take another option when your tastes change. 402 00:39:22,470 --> 00:39:27,020 Uh, and I think that's a good analogy that I've started to use more. 403 00:39:27,490 --> 00:39:32,410 But, uh, yeah, I think, like Maxime said, I really hope people are aware that there's more options available to them. 404 00:39:32,680 --> 00:39:45,005 It's endorsed by the WHO guidelines released July of 2024 and, uh, I think we can really help serve the, serve our communities better by ensuring they're aware of, of the various options available to them. 405 00:39:47,325 --> 00:39:50,285 Sara Dong: Thanks again to Maxime and Isaac for joining Febrile today. 406 00:39:50,995 --> 00:39:56,855 We will put some links to some great resources that they've worked on as well as the most recent WHO guidance. 407 00:39:56,955 --> 00:39:59,165 Don't forget to check out the website, febrilepodcast. 408 00:39:59,165 --> 00:40:03,780 com, where you'll find the consult notes, our library of ID infographics and a link to our merch store. 409 00:40:03,930 --> 00:40:07,470 Febrile is produced with support from the Infectious Diseases Society of America. 410 00:40:08,030 --> 00:40:12,089 Please reach out if you have any suggestions for future shows or want to be more involved with Febrile. 411 00:40:12,390 --> 00:40:15,040 Thanks for listening, stay safe, and I'll see you next time.