(P10) Preliminary observations and results of pre-exposure prophylaxis of HIV after 10 months of inclusion in a Swedish MSM cohort at Venhälsan, Stockholm

Författare/Medförfattare

Finn A Filén [1], Göran A Bratt [1], Magnus U Göransson [1], Ida T Ekengren [1], Bernt R Hildingsson-Lundh [1], Bo C Hejdeman [1]

Affiliates

Venhälsan, Södersjukhuset, Stockholm [1]

Abstract

Background
Pre-exposure prophylaxis for HIV (PrEP) is a preventive measure currently being rolled out worldwide. Swedish national guidelines (RAV-2017) recommend daily emtricitabine/tenofovir disoproxil fumarate for persons with a high risk of HIV infection, combined with other risk reduction measures. Concerns have been raised regarding increased risk behavior and subsequent increase of STIs in MSM taking PrEP. A waiting list for PrEP was started at our clinic in 2017 and the first patients were seen in October 2018. Follow-up is scheduled at 1 month, and then every 3 months. For the first 380 patients we present the risk factors for HIV, and at baseline and during follow up, STI incidence and renal function.
Methods
All patients are seen by a physician, and initially fill in a form to determine risk factors for HIV infection, and sexual health history. A score (“MSM risk score”, questionnaire modified from CDC) is calculated (range 0-69 points). Renal function is measured using S-Creatinine, e-GFR, U-Protein HC, U-Creatinine, and Protein HC/Creatinine ratio. If subsequent reviews are uncomplicated, patients are seen by a specialist nurse.
Results
Up to Aug 2019, 1005 patients had registered on the waiting list. Out of these, 380 have started, 40 have declined, 13 have started and later discontinued PrEP. No HIV infections have been diagnosed in patients started PrEP. One patient was diagnosed HIV+ at month 1, however he had been infected shortly before the initial consultation. Another patient was diagnosed HIV+ awaiting the first visit.
Results from the 380 followed up patients show median age 37 years (range 20-68). MSM risk score was high, with a median value of 28 (range 0-69). A score of >10 was seen in 90% of patients. A history of a previous STI at PrEP start was common (gonorrhea 66%, chlamydia 66%, LGV 6%, syphilis 26%, and Hepatitis C 1%).
At the screening visit, 11% had at least one ongoing STI (gonorrhea 4%, chlamydia 6%, syphilis 3%). One case of chronic Hepatitis B was diagnosed.
During follow-up (total 153 PrEP years), incidence of STIs remained high, with one or more STI episodes occurring in 16% of the patients.
Gonorrhea occurred at a rate of 24/100 PrEP years, chlamydia in 32/100 PrEP years, syphilis in 4/100 PrEP years. Rectal STIs (gonorrhea or chlamydia) occurred in 43/100 PrEP years.
At month 1, renal function analysis showed no significant changes in S-Creatinine or e-GFR, however the Protein HC/Creatinine ratio significantly increased from 0.5 to 0.8 mg/mmol. An increase in the Protein HC/Creatinine ratio of >2.0 mg/mmol at month 1 was seen in 2% of the patients. These were older (median 42 years) as compared with the median age of 37 years and due to this, PrEP was discontinued in one patient. No serious adverse events occurred. A further 11 patients stopped PrEP for various reasons.
Conclusions
PrEP is generally well tolerated with few side effects. Our data indicate that we reach a group of men at high risk for HIV infection. An increase in gonorrhea, chlamydia and syphilis infections had been observed before the PrEP program was initiated. Frequent HIV and STI testing at regular intervals as a part of the program could have an impact on undiagnosed rectal STIs. Close follow up of renal function is important in elderly patients with co-medication and/or co-morbidities.