By Adam King, CPhT, PRS, Master of Public Health student - Western Michigan University
The rate of new Human Immunodeficiency Virus (HIV) diagnoses is rising in Michigan.1 As of 2018, over 16,000 Michigan residents live with the disease.1 The six county region surrounding the City of Detroit is particularly hard hit with this illness, with over 65 percent of the diagnosed population in Michigan residing in that area.2 With no vaccine in sight, the public health best practice for preventing new illness is the use of pre-exposure prophylaxis (PrEP) used along with condom use.3 The population particularly at risk of contracting HIV is African American males who have sex with males.2 There are several clinical implications in community pharmacy when using this approach.
Current Pre-Exposure Prophylaxis Methods
The current accepted PrEP method is the use of older generation antiretroviral therapy along with barrier protection.4 Truvada was the first medication to receive this indication in 2018.5 In October 2019, Descovy was approved for the indication.6 It should be noted that the PrEP indication for these medications only applies to sexual transmission of HIV, use of PrEP for intravenous drug use is only partially effective and not widely studied.5–7
Insurance Coverage for PrEP
Many insurances still designate HIV therapy as specialty drugs and will often restrict access to select pharmacies. As of Oct. 1, 2019, Michigan Medicaid will only cover Truvada under the fee-for-service common formulary.8(p66) Each Medicare Part D formulary has its own criteria for PrEP coverage.
Since there are not currently generics for the PrEP medications, these medications do carry a considerable cost. The average price for a one-month supply of PrEP is around $2,000.9
Since HIV medication often comes from a different pharmacy than other medications a patient may take, drug interactions may become hard to detect. Common medications that interact with PrEP medications include hepatitis B and C medications, verapamil, chemotherapy, diuretics, immune modulators, immunosuppressants and some seizure medications.5,6,10 St. John’s wort should be avoided in patients using Descovy, as the herb will reduce the antiviral effectiveness.6 Drugs that impact renal function should be avoided in patients taking Truvada to avoid renal failure.5
Side effects of antiviral therapy should be conveyed to the patient when starting PrEP. Common adverse reactions include headaches, respiratory infection, sinusitis and diarrhea.5 These side effects occur in about 10 percent of patients. Patients with a diabetes diagnosis should be aware of potential kidney damage with these medications.5
While researchers continue to develop a vaccine for HIV, a rise in prescriptions for PrEP will be expected. With a low chance of developing drug-resistant strains of HIV, this intervention is currently the gold standard in HIV prevention. The use of the medications though is not a silver bullet as PrEP medications alone do not prevent all sexually transmitted infections. Barrier protection in the form of condoms must also be used to avoid potential co-morbid infections such as chlamydia, gonorrhea and hepatitis C.3
1. Michigan Department of Health and Human Services. HIV & STD’s in Michigan - an overview. July 2019. https://www.michigan.gov/documents/mdhhs/2018_HIV__STD_overview_660409_7.pdf. Accessed Nov. 10, 2019.
2. Division of Communicable Diseases. Epidemiologic Profile of HIV in Michigan 2018. Lansing: Michigan Department of Health and Human Services; 2018:44. https://www.michigan.gov/documents/mdhhs/2018HIV-Epi-Profile_620033_7.pdf. Accessed Nov. 10, 2019.
3. Kokolo MB, Fergusson DA, Cameron DW. HIV Pre-Exposure Prophylaxis (PrEP)—A Quantitative Ethics Appraisal. PLoS One; San Francisco. 2011;6(8):e22497. doi:http://dx.doi.org.libproxy.library.wmich.edu/10.1371/journal.pone.0022497
4. Patel RR, Mena L, Nunn A, et al. Impact of insurance coverage on utilization of pre-exposure prophylaxis for HIV prevention. PLoS One; San Francisco. 2017;12(5):e0178737. doi:http://dx.doi.org.libproxy.library.wmich.edu/10.1371/journal.pone.0178737
5. Gilead Sciences. Truvada package insert. DailyMed. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=54e82b13-a037-49ed-b4b3-030b37c0ecdd. Published May 18, 2018. Accessed Nov. 10, 2019.
6. Gilead Sciences. Descovy package insert. DailyMed. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=06f66e98-e6ee-4538-9506-6c1282cc14c1. Published Oct. 11, 2019. Accessed Nov. 10, 2019.
7. Guise A, Albers ER, Strathdee SA. ‘PrEP is not ready for our community, and our community is not ready for PrEP’: pre-exposure prophylaxis for HIV for people who inject drugs and limits to the HIV prevention response. Addiction. 2017;112(4):572-578. doi:10.1111/add.13437
8. Michigan Department of Health and Human Services. Managed Care Common Formulary Listing. Michigan Medicaid. https://www.michigan.gov/documents/mdhhs/Managed_Care_Common_Formulary_Listing_506275_7.pdf. Published Oct. 1, 2019. Accessed Nov. 10, 2019.
9. GoodRx, Inc. Truvada Prices, Coupons & Savings Tips. GoodRx. https://www.goodrx.com/truvada. Published Nov. 10, 2019. Accessed Nov. 10, 2019.
10. Liverpool Drug Interaction Group. Interactions with NRTIs. November 2019. https://liverpool-hiv-hep.s3.amazonaws.com/prescribing_resources/pdfs/000/000/079/original/NRTIs_2019_Nov.pdf?1572877409. Accessed Nov. 10, 2019.