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Clinical Education Initiative [email protected] TITLE: PREP FOR WOMEN: PREVENTION OPPORTUNITIES IN CLINICAL PRACTICE Speaker: Oni J. Blackstock, MD 3/15/2017 PrEP for Women: Prevention Opportunities in Clinical Practice [video transcript] [00:00:00] [Intro music] - [Jessica] Good afternoon and welcome to this month in HIV. Our March presentation is PrEP for Women: Prevention Opportunities in Clinical Practice. And will be presented by Dr. Oni Blackstock, who is an assistant professor of medicine and a primary care physician and researcher at Montefiore Medical Center in Albert Einstein College of Medicine in the Bronx in New York City. My name is Jessica Steinke. I'm the program coordinator for HIV/AIDS education and training department with the Mount Sinai Institute for Advanced Medicine. So before I officially introduce our speaker, I would like to thank our funders, the New York State Department of Health AIDS Institute, Clinical Education Initiative, and the Mount Sinai Institute for Advanced Medicine served as a co-sponsor of this Month in HIV. A couple housekeeping notes. For the duration of today's presentation, all lines will be muted to ensure that there will be no distractions during Dr. Blackstock's presentation. At the end of the presentation we will unmute all phone lines for the Q&A part. However, if you do not have a question for the presenter or if you are not presently speaking, we do ask that you please mute your phone line to limit distractions. And please do mute it rather than put your line on hold as sometimes that hold music starts which can disturb the webinar also. If you do have questions during the webinar, you can hold them until the end or you can type them into the chat box directed at myself and I can read them out at the end. At the end of the presentation you will receive an email with instructions on how to evaluate today's presentation and claim your CME or CNE credit. Please do remember that as I said this Month on HIV is supported via our New York State Department Health CEI grant and your participation in the evaluation process helps to keep this program free of charge for all attendees. So at this point I'd like to introduce our speaker, Dr. Oni Blackstock. Like I said, Dr. Blackstock is an assistant professor of medicine and a primary care physician and researcher at Montefiore Medical Center in Albert Einstein College of Medicine in the Bronx. Dr. Blackstock provides general and HIV primary care to patients at a Montefiore-affiliated federally qualified community health center in the South Bronx. Her clinical and research interests include improving engagement in clinical care and health outcomes for women with HIV as well as promoting HIV prevention among women at high risk. So Dr. Blackstock at this time, I will turn it over to you. [00:02:29] - [Oni] Great, thanks so much, Jessica. Thank you for the opportunity to speak on what I think is really an important topic. And one that I hope more healthcare providers and social source providers will become familiar with. [00:02:41] So I have no conflicts of interest to disclose. 1 [00:02:46] And the learning objectives for the presentation are, one, to discuss the evidence for daily oral PrEP's efficacy for women. Second is to describe women's perspectives about PrEP as a factor in PrEP uptake among women. And the third, to evaluate oral PrEP within the context of reproductive health. And just for the purposes of this talk I will be focusing on cisgender women, so women who are assigned female sex at birth and who currently identify as female. We do know that transgender women, women who were assigned male sex at birth, but identify as women are on the spectrum of women, bear a disproportionate burden of HIV. However, that will be a topic for another presentation. [00:03:40] In terms of the roadmap for my presentation, I'll speak briefly about the epidemiology of HIV in women, both nationally and in New York State. Then talk about PrEP as an HIV prevention tool for women and summarize the evidence for PrEP's efficacy. And talk about PrEP in the context of reproductive health. Then move on to how we conduct assessments of eligibility for PrEP as well as monitoring patients once they're on PrEP. And then lastly provide a brief example of a new PrEP technology for women that's further along in the research pipeline. [00:04:19] So I'm going to use a clinical vignette, that I'll weave throughout the presentation to highlight on some points. So we begin with Karen. She's a 30-year old Black cisgender woman who presents for a routine annual visit. She's treated for Chlamydia infection for about four months ago she reports. She says she's been struggling to pay bills and sometimes exchanges sex for money with two of her old boyfriends. They prefer not to use condoms, and she kind of feels like she doesn't really have much of a choice. Then you begin to wonder about her risk of future sexually transmitted infection, in particular HIV. [00:04:59] So now I'm going to talk briefly about the epidemiology of HIV in women nationally and in New York state. [00:05:05] Over the past 10 years or so we've seen very encouraging trends with a decline of about 20% between 2005 and 2014 in the number of new HIV diagnoses per year. So in 2005 about 50,000 new HIV diagnoses were made in the United States and in 2014 less than 40,000, which was a first. And as you can see in this chart, we've seen declines among most risk categories except for men who have sex with men. The turquoise line represents heterosexuals and within that a large proportion are women. And we've seen a decline of about 40% of the new HIV diagnoses among women. [00:05:52] This is another slide from the CDC which is really meant to highlight the racial and ethnic disparities that do exist among new HIV infections among women. So while it's great that we're seeing this decline, we're still seeing this persistence in terms of Black and African American women being disproportionately impacted by HIV as compared to other groups. 2 [00:06:16] This is another slide that highlights that point. So whereas Black/African American women comprise about 13% of the female population, they account for about 61% of new HIV diagnoses in the year 2015. [00:06:36] And this slide is meant to highlight the main mode of HIV acquisition among women, which among most women is heterosexual contact. Although we see among white women a larger proportion about a third of new HIV diagnoses are attributed to injection drug use. But I think because heterosexual contact is one of the main modes of acquisition of HIV among women it really speaks to the need for HIV prevention strategies that women themselves can control. [00:07:10] That is a slide that also is meant to highlight in addition to racial and ethnic disparities that we see geographic disparities in risk of HIV. And this is specifically looking at lifetime risk of HIV diagnosis. And as you can see, New York state is sixth in terms of risk of lifetime HIV diagnoses. And then we see the South also as the new epicenter of HIV in the country. [00:07:38] So with regards to New York state, there are about 112,000 people who are living with HIV. And about 30% of those individuals are women, which is slightly higher than the national number, which is about 24% of those living with HIV are women. [00:07:58] And then in terms of newly diagnosed HIV cases in 2014, we see that about 21% were among women as well. [00:08:10] And then similar to national trends, we also see that there are racial and ethnic disparities in who is newly diagnosed with HIV with women with Black and Hispanic women accounting for the majority of new HIV diagnoses among women. [00:08:28] So back to Karen's case. So you think about Karen's risk of HIV and you remember hearing about pre-exposure prophylaxis or PrEP for HIV prevention. And you wonder if women are using it and how well it works. [00:08:44] Now I'm going to touch on PrEP as an HIV prevention tool, and then move into summarizing the evidence for its efficacy in reducing the risk of HIV infection. 3 [00:08:55] So this is our HIV prevention toolkit. And it's incredibly encouraging. It's incredibly encouraging that we have this growing toolkit. However, when it comes to HIV prevention for women, there are very few methods that women themselves can control. So even when we think about female condoms or male condoms or even treatment as prevention, these all require male partner cooperation to varying degrees. And so what's really needed are safe and effective HIV prevention options for women that don't require negotiation for safer sex. And to me PrEP represents one such strategy. [00:09:47] So currently Tenofovir/Emtricitabine is the only medication approved for this PrEP strategy. It's been used, as you may know, in treatment for HIV over the last 10 plus years. And so PrEP involves taking an antiretroviral medication daily that's prescribed by a health care provider before a potential exposure.

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