Academy Guidelines and Recommendations for Pre-Exposure Prophylaxis (PrEP) for People Who Inject Drugs (PWID)
OVERARCHING BARRIERS TO PrEP UPTAKE AND RETENTION
- Frequency of in-person medical appointments
- Frequency of Laboratory Monitoring and HIV/STI Testing
- Patient costs of labs and follow-up care
- Incapacity for oral, rectal and vaginal swabs for STIs in many commercial labs
- Confidentiality concerns for young PrEP candidates who are on their parents’ health insurance
- Inconsistent messaging about who could benefit from PrEP
- Extensive and time-consuming CDC Guidelines (94 pages) is daunting for new prescribers
- Prescribing providers are understaffed for patient tracking and retention needs for patients lost to PrEP care
PrEP FOR PEOPLE WHO INJECT DRUGS - WHO QUALIFIES
All adults and adolescents who inject drugs and their sexual partners should be asked if they have heard about PrEP and given information on PrEP in a non-stigmatizing way.
All adults and adolescents who inject drugs and their sexual partners should be asked if they have heard about PrEP and given information on PrEP in a non-stigmatizing way.
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F/TDF Daily has been approved for all sexually active adults and adolescents
(>35kg/77lbs) who report sexual behaviors that place them at ongoing risk
for exposure to HIV and acquisition and people who inject drugs with an
HIV-positive injection partner or share injection equipment
Injectable extended-release cabotegravir PrEP has been approved for all sexually active adults and adolescents (>35kg/77lbs) who report sexual behaviors that place them at ongoing risk for exposure to and acquisition of HIV and people who inject drugs with an HIV-positive injection partner or share injection equipment.
The efficacy and safety of other antiretroviral medications for PrEP, either in place of or in addition to oral F/TDF, oral F/TAF or injectable cabotegravir have not been studied extensively and are not recommended.
CLINICAL ELIGIBILITY FOR PEOPLE WHO INJECT DRUGS - ALL OF THESE CONDITIONS ARE MET
- Negative HIV antigen/antibody test laboratory (preferred) with reflex confirmation or blood rapid test for patients who have NOT taken oral PrEP in the past three months or injectable PrEP in the past 12 months
- No signs/symptoms of acute HIV infection
- Estimated creatinine clearance ≥ 30 ml/min for daily F/TDF
- No contraindicated medications
FOLLOW-UP CARE
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Every 3 months/90 days
- HIV Ag/Ab test and HIV-1 RNA assay, medication adherence and behavioral risk reduction support
- Access to clean needles/syringes and drug treatment services
- Bacteria STI screening and testing for MSM and transgender women who have sex with men (oral, rectal, urine, blood)
- Assess renal function for patients ≥50 years or who have an eCrCl <90 ml/min at PrEP initiation
- Bacterial STI screening and testing for all sexually active patients (vaginal, oral, rectal, urine as indicated) and blood
- Assess renal function for all patients
- Chlamydia screening heterosexually active women and men (vaginal, urine)
RECOMMENDED BILLING AND CODING
GUIDANCE
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In light of the US Preventive Services Task Force’s "A" grade of oral PrEP, we recommend using the ICD-10 Codes
with the 33 modifier to maximize patient savings. Modifier 33 is a
CPT modifier used to identify medical care whose primary purpose is delivery of
an evidence-based service, based on recommendations from the US Preventive
Services Task Force. You may also want to use Modifier 90 when laboratory
procedures are performed by a party other than the treating or reporting
physician and the laboratory bills the physician for the service.
- Z79 – Intravenous Drug Abuse
- Z79.51 – Drug Abuse Counseling and Surveillance
- Z20.2 – Contact with and suspected exposure to infections with a predominantly sexual mode of transmission
- Z20.6 – Contact with and suspected exposure to human immunodeficiency virus (for serodiscordant couples)
- Z29.8 – Other Specified Prophylaxis
- Z29.9 – Unspecified Prophylaxis
- Z70.8 – Safe Sex and STI Prevention Counseling
- Z72.51 – High risk heterosexual behavior (recommend not using considered to be stigmatizing)
- Z72.52 – High risk homosexual behavior (recommend not using considered to be stigmatizing)
OTHER CONSIDERATIONS TO EXPAND PrEP ACCESS AND RETENTION
- Consider standardizing follow-up care orders in electronic medical records systems.
- Include the whole care team in offering information about PrEP.
- Familiarize yourself with behavioral interviewing to assess ongoing substance use and injection drug use habits.
- Familiarize yourself with taking a sexual history that is non-stigmatizing and shaming. Consider training on implicit bias and language use to talk with patients openly and honestly about their sexual behaviors.
- Offer substance use treatment at every visit.
- Offer buprenorphine referrals as appropriate.
- Prescribe PrEP for EVERY patient who asks for PrEP.