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
- Documented negative HIV Ag/Ab test result within
one week of initial injection/prescription
- Before starting injectable PrEP, the guidelines recommend providers assess HIV status using RNA quantification instead of an HIV Ag/Ab test
- 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.