The Curbsiders (00:03.246) Curbsiders podcast is for entertainment, education and information purposes only and the topics discussed should not be used solely to diagnose, treat, cure or prevent any diseases or conditions. Furthermore, the views and statements expressed on this podcast are solely those of those and should not be interpreted to reflect official policy or position of any entity aside from possibly cash like more hospital and affiliate outreach programs. If indeed there are any in fact there are not pretty much we are responsible if you screw up you should always do your own homework and let us know when we're

The Curbsiders (00:24.91) Welcome back to the Curbsiders. This is Paul Williams. Not joining me is Dr. Matt Watto. I'm trying to kind of match his energy, but I don't think I'm going to be able to. I am thrilled to announce that I'm not even going to tease it. I'm just going to say outright I am joined by the eminent, the excellent Dr. Beth Garbatelli. Garbs, how are you? Doing well. Getting through residency just one day at a time, one minute at time. Lightly exhausted. The usual. I still don't know.

how anyone does this during residency, but we'll talk offline. In any case, we did one of our famous Peabody Award winning, someday I'll get sued for saying that probably, but our episodes with the United States Preventive Services Task Force. In this case, we were talking about pre -exposure prophylaxis and their updated recommendation. Before we get into who we talked about, I'm just going to remind you that we are the Internal Medicine Podcast, and we use expert interviews, we use clinical pearls and practice changing knowledge. And Beth, since I have you here, why don't you tell us a little bit about who we talked to and maybe just...

one of the few things that we talked about. Yes. We had the opportunity to speak with Dr. John B. Wong. He is a member of the U .S. Preventive Services Task Force and a primary care internist. He also serves as the vice chair of academic affairs at Tufts Medical Center and professor of medicine at the Tufts University School of Medicine. He attended Haverford College and University of Chicago Pritzker School of Medicine.

He then went on to complete his internal medicine residency and a clinical decision -making fellowship at Tufts Medical Center, where he has been for the past 40 plus years. What an amazing career. We had a great conversation with him. We have a wonderful time talking with him whenever he joins us. I loved this conversation. I want to go into infectious disease. I'm an ID nerd. I love PrEP. I want to talk to everyone about PrEP. He...

highlighted some of the really nice patient -centered elements of this recommendation and gave us some good tips and inspiration for us to be more active and upfront in our history taking and being more proactive about talking to patients about PrEP. So without further ado, our conversation. And a reminder that this and most episodes will be available for free CME credit for all health professionals through VCU Health at curbsiders .vcohealth .org.

The Curbsiders (02:44.59) org.

Welcome back to the Curbsiders. We've been talking for a little bit now and we are thrilled to welcome Dr. John Wong on behalf of the United States Preventive Services Task Force to talk about an exciting topic. We're going to talk about their recommendation regarding the implementation of PrEP. But before we even get there, we usually like to get to know our guests a little bit better. And you were just saying, John, that your wife is a professional musician, which may have not even been your fun fact, but I want to catch this on the air. Tell us.

Tell us a little bit about that. What does she do? Not that we're, you know, not that she can even defend herself, but you've caught my interest. Now she's a professional violinist. She's played in the Honolulu Symphony, which is where I met her. And as she phrases it, the only reason she would have left Honolulu was to come and marry me. So I'm in a good place. Oh, that's beautiful. What a beautiful love story.

All right, well, we've covered the interesting fact outside of medicine. Were there any other hobbies that you wanted to share? It sounds like you might have had something else locked and loaded that was not that particular fact. Well, there's a number of possibilities that spring to mind. The one probably no one else knows of except my family is that I collect Marvel comics. And I got that from a friend of mine, actually a cousin, who unfortunately just passed away.

So it's sort of the memory of that. And so, gosh, 50 some odd years ago, I was already reading Spider -Man, Iron Man. My favorite was Daredevil. Oh, well, the movie really failed you on that one. I feel like that's the one in the franchise. It's the character, OK? Somebody who has a visual impairment, who is able to.

The Curbsiders (04:40.142) do amazing things in contrast to say some of the others. Yeah, it does have a pretty good story. I guess the only other question we like to ask is, do you have any advice? I'm going to selfishly tailor this to you. Do you have any advice for residents, either personal or professional? Oh, I've got a great one for you. You know, there's this phrase that bad decisions make good stories. So.

Before I took my American Board of Internal Medicine exam, right after the third year of residency, okay, I grew up loving corned beef sandwiches, but I didn't finish my last corned beef sandwich. And there was this tiny piece in the refrigerator that I could not resist. And the night before the exam, I ate it. The next morning, the morning of the exam, I developed...

diarrhea before I got to the test room. I go in, they say there's one bathroom and I'm just so word of warning before you have your American board of internal medicine exam, do not be tempted by any leftover. Oh my gosh. Oh, that's so I'm so sorry that happened to you. It's okay. I passed. Okay.

All right, well, and Dr. Garbatelli, as a future ID doc, I was excited to see where the story was going. I know. I was like, this sounds like a bored question. I think we're supposed to have a moxie soon. you, what was the infectious agent? Well, that's a beautiful segue. So we should actually probably get to the topic at hand. And we are talking about the idea and the recommendation, I guess the updated recommendation for pre -exposure prophylaxis. So.

As is our usual, why don't we start with a case and sort let that guide our discussion. Beth, do you have a case for us? Yes. Our case is from CashLac. It involves a new patient visit in our clinic. The patient was on our schedule, and he's a 27 -year -old man. We don't know much else about him. He has no major past medical history in the chart, no family history. As we are chart prepping, we are kind of wondering what important screening prevention topics we should be addressing. So to kick off the conversation,

The Curbsiders (07:03.086) Why did the USPSTF decide to address PrEP? So HIV infection remains a really important area. You know well as someone who's very interested in infectious disease. There were over 30 ,000 new cases in 2020, and that's probably an underestimate, right? Because we are in the midst of a pandemic. We also know that there are about 1 .2 million individuals.

in the United States living with HIV. And we also estimate that perhaps one in seven of them are unaware of their infection. So I'm just going to shamelessly plug our 2019 recommendation that everyone should get screened with HIV. I love that recommendation. At once. Yes. This is a really basic question, but what is PrEP?

I know that we just went over what that stands for, but what are the medicines that qualify as PrEP? So PrEP is, as you know, shorthand for pre -exposure prophylaxis, which in this case means taking a medication to try to prevent HIV infection. And in this case, because there are some potential adverse effects from the medicine, we recommend it as it was.

tested in randomized controlled trials for individuals who are at increased risk for HIV. So our new recommendation statement, Paul, as you asked about and mentioned, is that we continue to recommend pre -exposure prophylaxis or PrEP for individuals at increased risk for HIV to help prevent HIV infection.

And John, I know it's I'm always kind of interested in how the sausage is made. And I know sometimes with these recommendations, like every 10 years, we just kind of way back in and sort of see how things are going. And I know that's not a hard estimate, but I guess it's only been four years since the last recommendation about prep. And this one doesn't seem all that markedly different. Can you kind of speak to sort of what transpired or kind of prompted the task force to reevaluate or sort of restate their recommendation? Sure, Paul, you know, we always seek to update our recommendations. And on average, you know, we aim to

The Curbsiders (09:26.958) do them around every five years. And as you noted, this was a bit earlier than we usually do them. And in particular, what motivated us is that there is now a new form of PrEP. So initially there was one oral version. Now we have a second oral version, but most importantly, we now have an injection for it. And that is key because now we can work with our patients to help tailor.

the most appropriate medication, the one that they are most likely to take because either form of medication is both safe and effective, but they're only as effective if they're taken as prescribed. And so if a patient's more likely or would prefer to take a daily pill, we have an option for them. We've had an option since 2019. But now for those who would rather not take a pill, but sort of take a shot every other month,

we have an option for them. And so we, as healthcare professionals, can then work with the patient to say, how do you feel about taking a pill? And I'm sure like you have had patients who sometimes have trouble swallowing pills. So for them, the injection form might be right. Or they may be someone who says, you know, I have trouble remembering to take a pill every day. And again, because the shot is every other month,

it'll be easier for them. On the other hand, again, I'm sure we've all seen people who have neetophobia and would prefer not to do an injection, especially to give it to themselves. And again, for them, a prep as a pill is an excellent option.

Yeah, it's really wonderful that we have these different options for folks. I feel like it's so much more patient centered and just, you know, the stakes are so high for this. Not that the stakes aren't high for other types of conditions, but just the risks of missing a dose with an HIV medicine, you know, are so challenging to that individual and also the public health standpoint. Completely agree. You know, fortunately, as compared to when I was a house officer, we now have effective.

The Curbsiders (11:44.142) treatments for HIV. On the other hand, it's rarely curable, except in a very specific circumstances that involve some risk of harm for the patient. So it's avoiding lifelong medications to help control the HIV. So I agree with you fully. So to dig into that kind of nuance of the recommendation, who do we consider high risk for HIV exposure?

Yes, it's really important. The factors that place an individual at increased risk for HIV include activities specifically. And the activities include having sex with someone who has known HIV, having had a sexually transmitted infection yourself within the past six months, not consistently using condoms.

or not using condoms at all when having sexual activity, particularly with a partner who may be at increased risk. And also sharing drug injection needles, syringes, or other equipment. It's important for people to know that those activities can place them at increased risk for acquiring HIV. And we now have effective methods.

as we just talked about, that can help keep them safe from acquiring HIV. I'm not sure if you would know the data behind this, but I wonder if you have a sense of the general uptake in terms of like how consistently do we offer PrEP to the appropriate patients? I don't know if you have specific numbers in mind or not, but it seems like it's offered not nearly as often as it could be based on these recommendations at least. I think you're absolutely right. I don't have a specific number.

but it is clear it's being underutilized. You know, again, we're seeing at least 30 ,000 new infections every year, and those are just the ones we know about. We also know that there are disparities. We know that individuals who are Black are at higher risk for acquiring HIV in general, and yet they are

The Curbsiders (14:10.614) offered or we don't know about the offering, but they are five times less likely to be using or having the opportunity to use PrEP based on prescription patterns. And so there may be a number of reasons for that disparity and the task force is calling on all of us as healthcare professionals to do what we can to try to rectify that.

and to overcome any barriers and to help those individuals know that there are these safe and effective drugs that can help lower their risk. I feel like it's, and again, this will be more a statement than a question, which makes me the worst person on the planet. But I do think in my anecdotal experience, the history of bacterial STI within the past six months is a missed opportunity that I see all the time. You know, how often do you see that in the primary care setting and how often is it actually prompt a conversation about PrEP? It just seems like.

this is a chance. I just I think even having this recommendation out there just to remind people that prep exists is hugely helpful. I totally agree. And again, this notion in particular that we now have a new option for them to consider for especially for individuals who might not like to take a drug, a pill every day or would have trouble swallowing a pill. You've got a new option and it's safe and it's effective. And I wouldn't say you're the worst person.

Thanks, I appreciate that. High praise. No problem. I completely agree, Paul. I mean, I think these recommendations really address the fact that, yes, we want to be focusing on high -risk populations, but the term high -risk encompasses way more people than I think people might have previously included in their sort of framework for thinking about who to offer PrEP to. And I think it's important that we highlight that.

And I'm also copying you, Paul, because I'm just making a statement now too. Can I make a friendly amendment to avoid some of the possible stigma associated with saying high risk? We actually now use the word increased risk, and that in part represents the spectrum of activities that place individuals at different risk of transmission.

The Curbsiders (16:31.598) And so it's a slight modification of our recommendation statement, but it's in essence the same recommendation, but just using the term increased risk. I think that's an amazing distinction. I was going to actually, this actually dovetails nicely with the other point. Again, more statements that I'm making here. The recommendations, I think specifically mentioned that patients who asked for PrEP may not be comfortable disclosing the behaviors that put them at increased risk too. So that's that it's.

just because you haven't listed the behavior does not necessarily or the risk factor does not mean that that person should not be offered PrEP. It's just, you know, that's, I just thought that was such a nice sort of nuanced inclusion in the recommendations. So we'd still try right. As clinicians to understand, because there are other risks associated with particular risk factors. And, you know, it's challenging because these are sensitive topics.

and getting that open, supportive history of sexual activities, preferences, as well as even past history of, say, youthful indiscretion with injection drugs, which, for example, when I was doing hepatitis C research, even one injection could transmit hepatitis C.

Fortunately, HIV is not as transmissible, but still getting that kind of history is key. And it's an opportunity for to do that shameless plug for not only should we test for HIV one time, we should also check for HCV one time. And Beth, I'm sure appreciates that shameless plug. Yes. Well, when I'm giving people my spiel about testing them for HIV, I say we recommend testing everyone and the

people wonder what those risk factors are and it's being a human being who has blood. That's not in the books. Oh, no, just... I was going to pivot to the sort of more practical aspects of the discussion, but did you have any more like kind of recommendations focused, kind of backward research questions, Paul? I don't want to step on your toes. Nope, nope, nope. I was going to, I think I was going to ask about the practice considerations because we're, we're...

The Curbsiders (18:57.486) We're talking sort of around the actual screening questions, but I would love to hear sort of how that what the guideline says in terms of how to actually perform that. Yes, I agree. I was going to ask that question. Are there any important considerations when taking that social history, taking that sexual history and any tips or tricks that you utilize in your practice? You know, we do a history of the president on this. Patients will have a chief complainer, an annual preventive health visit. And I try to open it up with.

You know, obviously I want to know about your past medical history and any medications you're taking, over -the -counter medications and any drug allergies you've had in the past. But then we start talking about daily activities. And I try to preface that by saying, you know, there are things that you do on a regular basis that sometimes can affect your health and you're not even aware of it. And...

So as part of that, obviously smoking, alcohol, but increasingly I'm starting to ask about both fruits and vegetables in their diet. I asked about the sedentary lifestyle that Paul attributes his, well, I won't say. We don't have to drag me into this, Sean. Oh, okay. Sorry, Paul. Well, that we as clinicians mostly have, right? Cause we're sitting around a lot, but then as...

part of that, you know, again, trying to be supportive, trying to be non -judgmental. I'll try to ask, well, you know, have you ever experimented with injection drug use in your lifetime? And I ask that because there are some diseases that can be transmitted by blood. And again, if we can find it, if we detect it, we can treat it. We have effective treatments for hepatitis B, hepatitis C, HIV.

example. And then for sexual history, there are a number of activities that would place them at risk for both the infections that we're talking about. And so trying to be non -judgmental, to be open and inclusive, saying perhaps, you know, I have many patients who have different sexual activities that they prefer and different kinds of partners that they prefer, and that's totally fine with me.

The Curbsiders (21:24.044) And I'm asking because I'm really here to try to help you stay healthy and by if you're willing to share that information with me It's okay if you don't but if you're willing to share that information with you I can suggest some things that may help you stay healthy live a longer and healthier life. I What do you do Beth? I'm curious. I mean, I think it's one of those things where I I let the patient, you know, I

be willing to share what they're willing to share. And I think that sometimes it's helpful to schedule more follow -ups. If you feel like you haven't fully understood what's going on with this patient, give the patient the space and time to come visit and talk with you again. But I agree. I try to focus on having a really open -ended conversation. Ask what people are worried about. Is there any concerns that they're bringing to the visit?

And it's great. I do think a lot of the patients that I've been involved with for PrEP prescriptions have been, they've come to me asking for it. And I think that's great, but I don't want people to always feel like they need to be the ones coming to look for it. I wish that we could be more proactive in offering it to folks and letting them know it's available.

Paul, do you have any suggestions? It's nice of to ask. I do actually think that being kind of templated in your approach normalizes the entire discussion. You know what I mean? Even if I have someone who's, hi, nice to meet you, I'm Mr. Smith, I've been married to my wife for 47 years, even if they open with that line, I would still want to get to the sexual history. Well, who are your sexual partners and what does sex mean to you? And if he asks the same question the same way every single time and still gives someone a chance to answer, they realize that you're not asking out of specific judgment, you're not tailoring to who they are.

It's just part of your health assessment. And it just seems to sort of create a non -judgmental space that way. So I try to keep it just as even -killed and sort of, because I know with learners, and now I'm talking too much, but since you're nice enough to ask, we're trained to be so sensitive that we hype it up that patients might go into a panic. Like I asked this a lot, my patients sometimes are sensitive, I don't want to hurt anybody's feelings, so you don't have to answer if you don't want to answer. So we get nervous about asking the questions that the patient's like, oh my God, were they going to ask me? So I think if you just, you know, the same way that you ask, what medications do you take and just kind of keep it relatively.

The Curbsiders (23:39.15) part of the health history and not this sacred separate thing. It just seems to go better overall. Patients can feel when we're uncomfortable asking those questions and that makes them uncomfortable. So I think like having episodes like this where we talk about it frankly is helpful and I hope encourages people to feel more comfortable talking about it in their own practices. I'll just echo your comment about, you know, asking repeatedly or there are times when I haven't asked and for whatever reason they will bring it up.

perhaps because they feel finally comfortable with me. And again, I express my gratitude for them being willing to share. It's a big, for me, for them to trust us with things that they won't tell anybody else necessarily. So I mean, that's what makes the job humbling. But I guess along those lines, I know looking through the evidence review, it looks like the task force looked at some specific screening instruments to kind of identify.

patients who are at higher risk? Was there a recommendation to use any of those or are we just supposed to take our very good history and let that guide us? So the quick answer is we call that out as a research need. We found our evidence review team scoured the literature, both for the 20 randomized controlled trials that they found involving over 32 ,000 patients.

demonstrating the effectiveness and safety of PrEP. But in addition to that, they found 12 studies trying to look at risk instruments, sort of like the cardiovascular pooled cohort equation as one example to say, is there some kind of questionnaire that we could give that would give us an accurate, sensitive and specific way to identify individuals who are at higher risk for HIV? And

excellent candidates for PrEP. And I'll just say that when we looked at that data, it just wasn't of sufficient accuracy for us to make a recommendation. And as a result, we are calling for additional research to try to help discover those kinds of tools, perhaps even for individuals who may not be willing to express why they might be interested in PrEP.

The Curbsiders (26:02.798) This is going back to sort of the options. I know we talked about that a little bit at the beginning of the show, but can you walk us through the different formulations for PrEP? Just kind of like that brief, what you might give, say our 27 year old patient is interested in starting PrEP and he wants to hear more about the options available to him. Sure. There are two daily pill options. One is tenofovir, diazoprosofumarate.

in combination with M. tricytobine. A mouthful as always. The letters that are typically used for that are TDFFTC but I'll for once use the brand name for that which is Truvada. And then the other version of Tenafavir is

called Alephenamide with, again, M -Tricytobine. And the letters that are sometimes generically used for that are TAF -FTC. And that's brand name is Discovy. Now, one distinction between those two drugs is that, I'll go with the TDF -FTC, the tenofovir Truvada version. I said it one more time.

That is approved for adults and adolescents weighing more than 77 pounds or 35 kilograms in adults and adolescents for sexual transmission. The newer TAF, FTC version, however, is not FDA approved for the recipient of vaginal sex because it has not been studied in that.

population is the one distinction I would make between those two oral drugs. And the cabotec revere is the injection form. And as a startup, you would take an injection initially and then one month later. And after that, it would be every other month. Now, for all of those, taking them as prescribed is very important, but there are also, again,

The Curbsiders (28:29.326) Depending on when in that you may have missed a drug, there are recommendations for what to do if you should miss on occasion taking your dose of the medication. And I would refer listeners to the package insert or their trusted source to figure out what to do when a dose is missed. In our patient, we said that he's a healthy 27 -year -old. Let's say when we talk to him, we take that good history and, you know,

He doesn't have any medical conditions. Maybe we even grab some initial labs and he's got very normal liver function, normal kidney function, things like that. Are there any considerations that we should take into account when prescribing these medicines for folks who might have other conditions? Are there any red flags or concerning organ issues that we should be aware of? The trial suggests that

Again, depending on the oral or the injection form, that the adverse effects are for the most part what I would say not lifelong or significant. They tend to get better. There are things like nausea. Occasionally you can get a bump in the kidney function. Tends to get better or go away and certainly has not been shown to necessarily. There are some subtle weight

gain with some of them and not a lot of weight gain, but some. And then with the injection form, as with pretty much any injection, you can get some site reactions to the injection. I think what's most important though, Beth, and I'm sure this is true for your practice, is working with the patient to figure out which form would they be most likely to take on a regular basis? Which would they prefer?

The other part of this, just to elaborate a little bit further, is whichever form they take, it's important that they come back for regular checkups. Because these are highly effective and safe PrEP medications, but occasionally an individual may acquire HIV despite that. And so it's important for individuals to come back for regular HIV testing, because although PrEP is safe,

The Curbsiders (30:56.462) to prevent reception, it's not an effective treatment for HIV infection. And then it places that individual also at risk for transmitting infection to others. Yeah, thank you for highlighting that. And how frequently should we be having these patients come back in for HIV screening and STI screening? Yeah, about every two to three months. And thanks for mentioning the STI screening, because

As you well know, PrEP is safe and effective to prevent HIV infection, but it doesn't prevent sexually transmitted infections. So it's really important to make that clear with patients that yes, this will prevent HIV, but it does not help prevent any of the other sexually transmitted infections. And we should have you come back and not only get tested for HIV to make sure you haven't gotten HIV, but also...

any sexually transmitted infections that we can treat. And as you well know, we would continue to recommend safer sex practices, such as consistent use of condoms, which will also help reduce the likelihood of sexually transmitted infections. And one important consideration that I did not mention when I spoke about harms is there has been a concern about whether or not taking PrEP would lead to an increase

and sexually transmitted infections. And to date, we have not seen a signal for that in the studies that I mentioned, the 20 randomized controlled trials with over 32 ,000 patients. I will say the vast majority of those trials handed out condoms at the same time that they were involved in the study. So we're talking about a benefit from PrEP that's over and above.

I feel like that's something we should implement into our practice as well, even for patients we're not giving PrEP to, just give them kind of a goody bag on their way out the door. Oh, like the dentist office, right? Yeah. Well, one of my current mentors, and who's referenced often on the show, Daryl and Moyer talks about whenever you're having a conversation about your PDE5 inhibitors, that is you get out condoms at the same time. Like that is your chance to sort of revisit sexual health and that kind of stuff. So it's like there's never...

The Curbsiders (33:23.598) Wrong time to bring it up unless I guess it's like an acute dental complaint and even that. John, I wanted to ask in terms of the monitoring, so you mentioned we're having people come in probably every three months for HIV, possibly STI testing, checking their renal function. Which HIV testing should we be doing? When I think about HIV screening, I think about the antibody with the V24 antigen, I guess the fourth generation test. Is that sufficient or should we also be doing RNA viral loads for patients who are on PrEP? It's a really important question. And

You know, we used to only have the antibody test and now we have joint tests where you can test for both the antigen and the antibody. And if it's a new patient at first visit, we can inquire about whether or not they've had a possible exposure recently because it takes weeks before antibodies will develop. And

In fact, even during the trials, some of the breakthrough infections were because of HIV being present at the start. The HIV infection had been present at the time of enrollment. So the failures were not because the prep failed, but because we or the trialists failed to detect the HIV at onset. So the recommendation is to test for both the antigen and the antibody, usually at that time.

first visit before starting, as well as potentially other sexually transmitted infections, as well as getting perhaps some baseline laboratories with regard to liver, which can be a concern, and hepatitis B and hepatitis C perhaps too. And then one other kind of counseling point question, how quickly does PrEP become effective in preventing HIV transmission? You know, it's...

A question that when we look at what was done, we don't know how long it takes to get to maximum effectiveness. It was not examined with, say, different doses of the drugs. If you look with the tenafavir pill versions, we usually think that three to four doses will get you normally up to close enough to steady state.

The Curbsiders (35:51.55) What we do know from looking at the dosages or the levels that occur within the blood and the rectum, that it takes at least a week of taking that pill to get up to a steady state dose in the blood and the rectum. For the vaginal cervical area, it takes about three weeks to get up to that level.

For Cabotekravir, again, we don't know how long you have to take it to get up to steady state. We do know that after you get at least three doses, you're about at the max. But again, that's going to take one month, second month, and then the fourth month. And then again, there's some makeup doses depending on when you missed or if you missed, say the second month or the third month or the fourth, sorry, second month or the fourth month.

to try to catch you back up.

I'm making a face for those who are just listening. I wonder if I shouldn't try the famous Matt Water recap. If now do you think is the right time for that? I think that would be great. It won't be as smooth as him because he's a pro. So John, you'll correct me and you'll make sure that I don't say anything too egregiously stupid, but it sounds like the USPSTF is recommending PrEP be offered for patients who are at increased risk for the acquisition of HIV. And those groups should be sexually active adults and adolescents.

at least 35 kilograms based on studies who are at increased risk by dint of having a partner who has HIV, having a recent history of bacterial STI, a history of inconsistent or no condom use with partners whose HIV status is not known. And then along those lines also a person to inject drugs specifically who share injection equipment or have a drug injecting partner who has HIV. And in terms of what we have to offer, we have the two different pills and I'm not even gonna try to say that.

The Curbsiders (37:50.158) the generics. We'll say the TDF -FTC and the TAF -FTC are the two medications. The TAF is the one that is not for individuals at risk from receptive vaginal sex. Of those patients would be getting the TDF -FTC, which is Truvada. I'm going to say the one time just for clarity's sake. And then we also have the injectable cavitegravir for those patients for whom an injection might make more sense. We'll be screening for this higher risk just by taking a good question, by doing a good history because we're all great primary care doctors.

We will also be testing patients for HIV prior to the initiation of therapy, as well as at least getting a baseline renal function, and then also assessing adherence, assessing the need for repeat STI screening, and doing that sort of almost quarterly HIV testing and renal function testing as the patients follow up with this. And then, of course, this is not sufficient just to treat or prevent all STIs. So we're talking about safer sex with consistent barrier contraception if we're able to, and sort of just safer sex practices in general.

Did I say anything dumb or misstate anything or miss anything egregious? Not at all. But most importantly, working with the patient to figure out what might work best for them. Excellent. All right. I think that's all the questions that I have, John. Dr. Carpitali, any questions from you? I think that was a pretty good take home point, too. Do you have anything else to plug? Any resources that you recommend for folks to utilize when thinking about this issue?

Thanks so much for asking that, Beth. The CDC has a wonderful set of guidances, recommendations that are appropriate for both us as healthcare professionals as well as for patients. We also at the task force have a PDF both for patients and clinicians, and it has to do with us talk about prepping HIV prevention. And I'll do one more shameless plug.

We have an app. I was going to say, you guys have a great app. It's a good app. It's called Task Force Prevention, and it's available for download for Apple and Androids. That's terrific. Good to know about. Great. Well, this has been extraordinarily helpful. Thank you for taking time to talk with us about this important topic, and I'm sure we'll talk to you again soon about future recommendations. So thanks so much, Sean. Oh, thanks so much for both of you.

The Curbsiders (40:13.582) for helping us get the work out. Really appreciate it.

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