All right, everybody, welcome back. My name is Jeff Darna. I'm a member of the American Association of Nurse Anesthesiology Professional Development Committee. And just a couple of quick reminders before we begin. Please use the app to access notes and submit questions virtually if you would like. If there's time at the end of today's session, we will allow for questions. There's also a mic that's right up here in center stage for you to come up to and to be able to ask our presenters questions again if time permits. Please do complete your evaluations using the app at the end of each session. And you must submit your entire session evaluations and overall conference evaluation by Monday of September 9th, 2024 at 12 noon Pacific time. Make sure you write that down because it's really important because after that time period, you will not be able to claim CEUs for this Congress, okay? That window closes and once it's closed, we cannot reopen it. Importantly, we are looking for abstract submissions for next year. That process is going to open up on August 14th. Please do go to the AANA.com and look at our parameters for submission. There's also going to be a video that's posted that walks you through the process, helps demystify it to make sure that your abstract meets all of the parameters during our blind review. Now I'd like to introduce our next presenters, Dr. Jennifer Bajamdar and Jake Forrester. Dr. Bajamdar is a specialty director of the Nurse Anesthesia Program at Hunter College and a nurse scientist at Memorial Sloan Kettering Cancer Center. Mr. Forrester is a CRNA at New York University, Langone, NYU grad here. Please join me in welcoming our presenters as they present post-exposure prophylaxis, and what anesthesia providers need to know about the important HIV prevention tool. Hi everyone, thank you so much for being here this morning. We're really excited to present to you about this topic. My name is Jenny Bajamdar, as they said, I'm the assistant specialty director at the new Hunter College Program in New York City and a nurse scientist at Memorial Sloan Kettering. Jake. Hi everybody. My name is Jake Forrester. Like he said, I am from NYU Langone, and I am the current clinical coordinator. So let's go ahead and get started on our topic. So regarding disclosures, Jenny nor I have any conflicts of interest, and we will be discussing off-label use during our presentation. So let's talk about learner outcomes. So in our presentation today, we'll cover three broad topics. The first, which I am going to discuss, is the current state of HIV and HIV prevention in the United States. Then I'll be covering PrEP indication, dosage, and routes. I'll hand it off to Jenny, who will describe the implications for anesthesia providers, including medication interactions, effects of PrEP on the body, and anesthetic implications. And then she'll finish off by discussing ways to decrease stigma and barriers associated with PrEP as well. So currently 1.2 million people in the United States are living with HIV. This number reflects the ongoing challenges in managing and preventing the spread of the virus despite advances in treatment and awareness. Infection rates from 2018 to 2022 have decreased by 12% in the United States. This decline is a positive sign, indicating that our prevention and education efforts are having an impact. However, there is still much work to be done to reduce new infections. PrEP or pre-exposure prophylaxis is currently our best preventative for HIV due to there not being a cure for HIV. PrEP involves taking a daily medication that significantly reduces the risk of contracting HIV. It is especially recommended for individuals at higher risk, such as those with HIV-positive partners or those who engage in high-risk behaviors. Condoms also help in preventing HIV, but they're not as effective as PrEP. While condoms are a critical tool in preventing the transmission of HIV and other STIs, they do not provide as high a level of protection as PrEP. Additionally, condoms do not prevent HIV transmission among people who inject drugs, highlighting the need for PrEP. Typically, condoms are about 90% effective in preventing HIV. So over 2 million people in the world were infected with HIV in 2021 alone. This statistic underscores an ongoing global challenge of HIV, highlighting the need for continuous efforts in prevention, education, and treatment. Over 31,000 people living in the United States were diagnosed with HIV in 2022 alone. This figure illustrates the persistent presence of HIV within the United States and the importance of regular testing and early diagnosis to manage and prevent the spread of the virus. According to the CDC, 49% of patients newly infected with HIV are in the southern region of the United States. As a guy from South Carolina, I was wondering what the CDC considered a southern state. So I looked it up, and the CDC included Maryland as a southern state, which, in my opinion, have a different opinion on, but that's a discussion for a different day. The statistic shows that the regional disparities in HIV infections and the need for targeted education towards the south. Within the United States, 13% of the HIV population are unaware that they have HIV. So this lack of awareness is a significant barrier to controlling the spread of the virus. It highlights the critical need for increased access to testing and education to ensure that more people know their HIV status and can take appropriate measures to protect their health and the health of others. So now we're going to talk a little bit about the history of PrEP. So PrEP was initially approved in the United States for HIV prevention in 2012. This was the year when the medication Truvada came to market, marking a significant milestone in HIV prevention. By 2017, PrEP was being utilized by 13% of eligible individuals. This uptake shows an early but growing acceptance of PrEP as a preventative measure. By 2021, that number had increased to 30% utilization, demonstrating a significant rise in awareness and use of PrEP. Since 2018, though, the HIV infection rates in the United States have been steadily dropping. This decline seems to correlate with the increase in PrEP usage, highlighting the effectiveness of PrEP in preventing new HIV infection. So we're going to talk a little bit about pharmacology. So the first two medications approved for PrEP in the United States were Truvada and Dyscovi, which are both oral medications that are taken on a daily basis. Truvada and Dyscovi are similar formulations, while the only exception is Truvada is tenovivir disapraxal fumarate, or TDF, while Dyscovi is tenovivir alanthenamide, which is TAF. These medications are in the antiviral class as nucleoside analog reverse transcriptase inhibitors, NRTIs for short. We will discuss the mechanism of action of NRTIs later on. In 2021, Apertude was approved as the first intramuscular injection medication to be used as PrEP, for PrEP. Apertude is a different, is in a different class known as intergrace inhibitors. The pharmacology of these medications is very favorable due to their simple dosing, limited medication interactions, and effectiveness when doses are missed. Apertude improves on these benefits even further due to its route of administration and due to it not being as harsh on the renal system compared to Dyscovi or PrEP. In regards to efficacy, PrEP reduces HIV transmission up to 99% in people having sexual intercourse and by 74% in people who inject drugs. I feel like that phrasing is a little different. I think there's a better phrasing, but that's currently what we use, or the CDC uses, for people who have IV drug use. So medications, it's very similar to the slide before, just laid out a little differently with some additional information. So Truvada is the only PrEP medication approved for people who inject drugs. Dyscovi is very similar to Truvada, but has only been approved by the FDA for use by people who were assigned male at birth and are at risk of HIV through sexual transmission only, not for people who inject drugs. Both Truvada and Dyscovi are oral medications that need to be taken on a daily basis. Both also require HIV renal hepatic testing every three months. When the patient sees their primary care provider for these testings, the provider will also sometimes include an STI panel at this time. One consideration for Truvada over Dyscovi is that it does have the potential to worsen hepatitis B infection. Another thing, too, is that both of them affect the renal system, but Truvada seems to affect it a little more harsher than Dyscovi. So let's talk about Apertude a little bit. It's a little different because it's an IM injection that has to be provided by a provider. You can't, like, pick it up from a pharmacy and do it yourself. This medication would have, would make you have to see your primary provider every two months for testing and for the injection after the initial two doses that are one month apart. The side effect profile for Apertude is significantly better than Truvada or Dyscovi, with the only requirement being that you weigh at least 35 kilograms. Before we get into the mechanism of action for PrEP, let's just take a deep breath and remember that we'll get through this explanation together. I'll do my best to break it down in a way that makes sense, but also does not make you regret coming to our lecture today. So remember the class, the medication class of PrEP is a nucleoside analog reverse transcriptase inhibitor. So I'll usually say NRTI. And when I talk about NRTIs, I am specifically referring to Truvada and Dyscovi. So the mechanism that HIV works, for HIV to convert its RNA to DNA, it uses an enzyme called reverse transcriptase to complete this task once it enters the human cell. HIV can further replicate itself to infect the human by converting its RNA into DNA, and this is what will cause the patient to develop HIV. So the role of PrEP. So when the DNA is being built by the HIV virus, it uses, sorry, when DNA is being built in the human, it uses building blocks called nucleosides. PrEP is structurally similar to the natural nucleosides found within the body. So when HIV converts its RNA into DNA, it will accidentally incorporate the NRTI molecule into the DNA instead of the natural nucleoside. Once this accident happens by HIV, the rest of the conversion is blocked by the NRTI, thus preventing HIV from further replicating and infecting the person that's taking PrEP. So the administration of PrEP. Both Truvada and Dyscovi need to be taken at least seven days for them to be most effective in preventing HIV from receptive anal sex, but they have to be taken for at least 21 days for them to be most effective against receptive vaginal sex. It is important that individuals on Truvada or Dyscovi undergo HIV renal and hepatic testing every three months. This ensures that the medication is working effectively and monitors for any potential side effects. So Apertude requires a different administration method due to it being an injection and it requires your provider that you see for this to provide it. Initially patients will receive two injections one month apart. After the initial doses, they'll receive their injections every two months in the office. Similar to the oral PrEP medications, patients receiving Apertude should have their labs performed every two months to monitor their health and effectiveness of medication as well as to make sure that they are still HIV negative. The advantages of Apertude is that they have a better side effect profile compared to oral PrEP medications. It is particularly suitable for individuals who may have difficulty adhering to a daily pill regimen or suffer from renal disease. Another way PrEP is being administered is called on-demand PrEP. So on-demand PrEP is also known as 211 PrEP and places like Paris, Amsterdam and the United States are prescribing PrEP in this manner sometimes as well. So initially you'll take two pills, two to 24 hours before anticipated risky sexual behavior. The closer the pills are taken to intercourse, the more effective they will be. After the initial dose, the individual will take one pill 24 hours after the initial dose and then they take another pill 24 hours after that. This method is good for, is a good option for individuals who do not have frequent risky sexual encounters or do not routinely have sex with partners who are HIV positive. It also provides flexibility for those who might not adhere to a daily medication schedule. So now I want to hand it over to Jenny so we can go over the scoping review. Okay, thank you Jake for that wonderful overview. Now that we've gone over the big broad context of what PrEP is, I really wanted to dive into what does that actually mean in the context of perioperative period. So in order to do that, I, we decided to do a scoping review. So the first thing I'm going to do today is just describe what a scoping review is. It's a type of literature review that I've just only recently become familiar with and I think it's a really great tool so I just wanted to share it all with you about that. Then I'm going to talk about this another great tool called Covidence. That is a software program that helps you do systematic reviews. We used it for this scoping review. So I'm just going to, again, provide a little overview of that great software program. And then I'm going to get into the results of our scoping review, and then provide the key takeaways that we learned. So let's get into what a scoping review actually is. A scoping review is a type of research synthesis that aims to map the existing literature on a particular topic. And it provides a good overview of all the available evidence that is out there. Unlike a systematic review that looks at a very, very specific research question and includes a rigorous appraisal of the quality of included studies, scoping reviews are a lot broader. And again, it's more exploratory questions. So it really makes it ideal for the topic that we're looking at today. So again, let's dive in a little bit more about what that actually means. So scoping reviews can cover a wide range of literature. And again, they provide an overview of the available evidence. They are used to identify the gaps in research, clarify key concepts, and explore the extent, range, and nature of research activity on a given topic. The primary aim of any scoping review is to map the existing literature of a given field, identify what evidence is available, and what studies have been conducted in that area, and what are the key characteristics and findings of those studies. They're typically used to address, like I said, broad, really exploratory questions. And they're really useful for topics that haven't been extensively reviewed before, which, again, is like our one today. So what's really helpful is that by providing a comprehensive overview of all the available literature, scoping reviews can really highlight the evidence that's lacking and where future research is really needed. This is really helpful in informing future research agendas and for policymaking. So I just want to hit home again. I love scoping reviews. So scoping reviews are really valuable tools for summarizing a breadth of literature on any given topic. You can use it to identify gaps in knowledge and it can inform future research decisions. And it really provides a really good overview of all the existing evidence. And it's particularly useful in an emerging or complex fields of study, which is why we used it for this topic today. Our scoping review aimed to enhance our understanding of PrEP medications in the perioperative context by examining pharmacology, side effects, and drug interactions. So I just wanted to go into, again, what those key steps of any scoping review involve. We followed the PRISMA extension for scoping reviews and the Arkezy and O'Malley framework. And these are the key steps, like I said, that every single scoping review should have. The first is to identify the research question. And that is, you want to define it to be clear, concise, and that guides the scope of the whole review. You want the research questions to be broad enough so that they can include a wide range of literature, but also specific enough so it actually gives you a meaningful insight, so it is useful. It's helpful to include the population, the concepts, and the context when you're formulating these questions. So for this scoping review, our research questions were, what is the pharmacology of antiretrovirals used for PrEP that anesthesia providers may encounter, which that piece Jake already reviewed for us today, then we also wanted to look at, what are the pharmacological interactions between PrEP and anesthesia or other perioperative medications? And what are the current recommendations for continuing PrEP during the perioperative period? Finally, we also wanted to look at, how can anesthesia providers play a role in reducing barriers and stigma surrounding the use of PrEP for HIV prophylaxis? So once those research questions have been identified, the next step is to develop a comprehensive search strategy in order to identify all relevant literature. First, you select appropriate databases. They can be things like PubMed, InBase, those kind of things, and then you create search terms that are a combination of keywords and subject headings related to the research question, and then you also include inclusion and exclusion criteria that are very clear and to ensure consistency and relevance. Once you've developed that, the next part is to start screening the literature. So you wanna make sure that all of the studies that you include are relevant to the research question. It includes two steps. The first step is the title and abstract screening, and that's just an initial screening of all of the titles and abstracts that you look at against the inclusion criterion. Then you go to the full-text screening, which reviews all the full-text for potentially relevant studies to make those final inclusion details, and then once you've done that, you extract the key information from those included studies. So you wanna develop a standardized form in order to do that, and that way you collect the same data from every single study. Those can be things like study design, population, key findings, instruments used, those kind of things, but you wanna make sure it's also consistent, so you wanna be using the same form and then checking each other that the data is correct. Once you have all that information, then you get to synthesize and present the finding. That can be done in a couple ways. These can include a descriptive summary, which is a narrative that really identifies all the studies, highlights the key themes, patterns, and gaps in the literature, and you can also use visual representations, including charts, tables, and diagrams that really help illustrate the findings and make it easier to read, and then once you've done that, you discuss the implications for findings for practice, policy, and future research, which gets me into the great program that makes it all easy, Covenants. So it's, again, it's something I wasn't familiar with until recently, and I've always felt that literature reviews, systematic reviews, are very daunting and hard to get organized, and this program just makes it really, really straightforward and guides you through the whole process, so it's a really, really useful tool. Most institutions at this point have access to it, so you should be able to get access to it for free through your institution as well. So Covenants is a web-based software platform that is designed to streamline the production of systematic reviews and all other types of literature reviews. It's a whole set of tools that facilitate all the different stages of a review, and it makes it easier for researchers to collaborate and manage the large volumes of literature really efficiently, which is, I think, what's really, really important. Different things that it can do. You first start by importing all your references. That's one thing that's, again, really, really useful is that you can import references directly from the search databases or through your reference management system, and it actually can be done in a batch importing, so it can easily bring in a large number of citations, which, again, is really, really useful. Then, for the title and abstract screening, it's, again, really easy. You can actually even do it from your phone. You can swipe left and right, which is really fun, and it's really user-friendly. It's really easy to screen those titles, and what's also nice is that different people can be working on it at the same time, so it's in real time. You can be collaborating, and people can also be working on it when they feel like it. You don't have to be doing it together, which is really nice. Then, for the full-text screening, you can actually upload all of your articles into the Covidence, so it's really easy to actually look at those and decide if you're not including it or including it and select the reason why, which is really nice, and then, finally, they have a data extraction tool that's customizable so that you can actually have those full-text articles, and then you can just pull from it really easily, and then it gives you a really nice, beautiful form that you can ultimately download and include into your final manuscript or presentation, so the other part that's great, which I absolutely love, is that you also can get a Prisma flowchart based on everything you've done, so it's really easy to read. It's really transparent, and it also shows everybody exactly why you made the decisions that you made at each different step, so it can be replicated later on, and those charts can be kind of tricky to make, so it makes it really pretty and makes it really nice, so I have our Prisma chart that we'll be showing you in just a second, so now that I've hopefully gotten you all excited about scoping reviews and this great Covidence program, let's dive into what we actually did for this current student, so the search strategy that we did was included four databases. We did PubMed, Embase, CINAHL, and Cochrane Review, and we used a combination of the search terms that were relevant. There were things like PrEP, perioperative surgery, HIV, those kind of things, and we included also bibliography and citation searches to make sure that we were getting all of the available data out there. One of the key things about a scoping review that's different, which I mentioned before, is that we included all types of research, so it doesn't have to just be original research or randomized controlled trials, which is the kind of studies that you would need for different types of literature reviews. This could be case studies, white papers, letters to the editor. We were trying to just get a whole understanding of what all the literature was that's out there on this topic. We excluded any studies that were, or articles, that were included or focused only on antiretrovirals that were not currently used for PrEP, and we also excluded studies that were not relevant to the perioperative period in any way. We had two authors looking through and screening the titles and abstracts and the full-text articles, and then we discussed any issues that we had between us. Initially, we had over 2,000 citations that we, and titles and abstracts that we screened. We identified 124 full-text articles, and then we narrowed it down to six to do a full review on. Those were two meta-analysis, one systematic review, two Delphi method, and one cohort design. And here's this beautiful Prisma chart, because again, those are such a pain to make, and it makes it so nice for you. Again, I just wanted to highlight that it is also really helpful because it includes the reasons why you decided to exclude them from the full-text and goes into that detail, which is really helpful for, again, transparency and for replicating your data. So let's get into the exciting results. The two really big, important things that we found in the literature, the important pharmacological interactions, really were renal toxicity and the potential for increased levels of hypertension and increased statin use. We'll go into this a little bit more then. So formulations of PrEP that have synovivir put patients at risk for nephrotoxicity, and that's the biggest thing that you need to watch out for. But the good part is is that it really is largely reversible. But it's, just so you know, it's also contraindicated for any patients where their creatinine clearance is less than 60 milliliters per minute, and it's really, really important to monitor their renal function every three months once it's started. So the meta-analysis have shown, in general, these are very mild symptoms that they've had and adverse events, and reversible, but it's just, again, important to watch for. So while other nephrotoxic agents and NSAIDs are not absolutely contraindicated, they may increase the risk of renal impairment, so you really should probably be careful, especially for those that are predisposed to any kind of renal dysfunction. And the people that would fall into those kind of categories of predisposed to renal dysfunction would be patients that are over the age of 40, if they've had been on these medications for a long time, or if they have lower baseline renal function at the time when they started these PrEP medications. But again, one of the key things is that most of these studies were only conducted over a period of about three years, at the very most. So we just don't really have an idea about the cumulative renal toxicity, which is one of the really, really big areas that needs further research, which we'll be getting into in a little bit. The other really big thing I wanted to highlight is there was a pretty recent cohort study of almost 7,000 patients that looked at dyscovue users that did not have pre-existing hypertension or use of statin therapy. It found they had an increased risk of developing both of those things once they were on it, and it is notable that dyscovue was a higher risk, which is the same dyscovue, TAF. Those had higher risk for the hypertension and statin use compared to the Truvidia TDF. In particular, it was for, again, individuals over the age of 40, and those that had higher other issues that put them at risk as well. So what do we need to know about patients that are using PrEP in the perioperative period? The key thing is that the efficacy of all of these medications is closely tied to patient adherence. So PrEP needs to be continued for as long as a patient is at risk for HIV infection, and interruptions to PrEP needs to be avoided at all costs. The other important thing is that these medications can be taken with food, without food. There's no issues with that. So the preoperative, perioperative, fasting, postoperative fasting, any of those things really are not going to have any impact on PrEP, so it shouldn't really affect any of the administration. The next thing that a lot of the studies really highlighted and really addressed were the barriers and stigma. So the issue is that PrEP is an HIV medication, and it can be easily mistaken by providers as the same medication taken by HIV-positive individuals, which leads to a lot of stigma by association. So both potential and current PrEP users have reported concerns that others will think that they're HIV-positive because they're on these, they're taking PrEP. So patients may not tell you that they're on it because they're concerned. And they're also concerned about what the associations of being on PrEP are, if there's any moral, cultural attitudes, stigmas, beliefs about what that means about their risky behaviors, and the character of those people that take them. So patients that are using PrEP may face difficulty, they may be worried about obtaining insurance and employment, and given association with those risk behaviors. Those are things that have all been reported. So let's bring it all together, and what's the overview of what that we learned from looking at all the literature? The really big key that we found was there was no specific anesthesia medication contraindicated for patients that were on PrEP. No interactions, no drug interactions, that was anywhere in the literature. But given the risk of nephrotoxicity, NSAIDs and any other nephrotoxic agents should probably be used with caution in these patients. And it's also really important just to ask any patients if their prescriber had any concerns about PrEP and their renal function, and just to make sure that you're looking at those labs for any kind of risk of renal insufficiency. Also, you should consider the risk, especially for patients that are on DysCOV or TAF, and TDF for that matter, but more for the TAF, the DysCOV one, that they can be a higher risk for hypertension, hyperlipidemia. But again, the part that was really striking is there is such a gap in the literature regarding this. There was really very, very little about interactions about the medication specific to the perioperative period, which really shows that there's a lot of research that needs to be still done in this field. Next, about continuing PrEP during the perioperative period. It really, unless you have some other really specific reason, PrEP should be continued no matter what, and it should not be interrupted during the perioperative period. There was no evidence that we found for stopping PrEP, but there really wasn't literature on it either way. So while everything supports continuing no matter what, it doesn't say whether or not there's any reason to not. So although that's the conclusion that we've come to, it's not based on a lot of strong literature. And then finally, getting into the barriers and stigma, which is a lot of the reason that we really wanted to even do this presentation. The CDC estimates that 1.2 million people in the US could benefit from using PrEP. There's actually a huge national strategy in place headed by the US Department of Health and Human Services to reduce HIV infections by 75% by 2025 and 90% by 2030. And one of the key tools to do this is PrEP. Most insurance plans cover PrEP, and it's including state Medicaid programs. And actually, under the Affordable Care Act, PrEP must be free under most insurance. So that should not be a barrier. However, previous studies have really described that people are hesitant to disclose that they're using PrEP because they don't want the stigma, and they don't want the stigma associated with what that means to be on PrEP. So what can we do as clinicians? Clinicians can really foster a welcoming environment and encourage patients to disclose about the medications that they're on. Patient and provider effective communication is really going to be essential at every single stage of the PrEP care continuum, which includes the perioperative period. It's really important to be sensitive without any judgment, any assumption about the reasons for use, and should be used when patients are asking about things like PrEP. You should really try to make it as supportive social environment as possible, which the literature has shown by creating that, so that patients are more at ease about discussing these things with their healthcare provider. And just having an awareness has been one of the things that's been really effective. It doesn't mean that you have to be an expert, but just even knowing that somebody can take PrEP as a preventative tool, and it's not for an HIV medication, and it doesn't mean that they engage in necessarily risky behaviors, that you can be on it, and there's, again, a lot of reasons for it, can really reduce a lot of that stigma and a lot of that fear that people may have about talking about it with their healthcare providers. So, it can also, because that's the problem, is that if they feel that they can't talk about it with somebody, or they have a negative experience, it makes it so that they're scared to then talk about it with other people. So, again, even though that we're just some, one tiny piece in their healthcare journey, having a negative experience can make it so that they don't want to talk to other healthcare providers about it. And also, the other key, is that we want to make it a really supportive environment so they tell us that they're on it, because they may not even want to tell people that they're on it. So, we need to reduce, we need to increase the prescribing of PrEP to at-risk individuals, and to meet those goals that have been set by the U.S. Health and Services. We really, really need to work on dispelling stigma and providing PrEP-competent care throughout the whole continuum. So, in conclusion, while there's a lot of studies that show that there's, that are focusing on the use of PrEP, we're seeing a huge increase of PrEP. There's still some major, major, major gaps in the literature, and particularly in the understanding of the perioperative implications of PrEP medications. So, studies really need to focus on detailed guidance on the potential drug interactions, particularly with our anesthesia medications, because there's not much out there right now. This review also really highlighted the need to look at all of the pharmacological interactions of all of the perioperative medications that are being used to make sure that PrEP continues to be safe throughout the whole surgical setting. The other really important thing is, we need to address barriers such as stigma and misinformation, which is really going to be crucial in making sure that patients report that they're on and they're using PrEP, and it also enhances our PrEP, our HIV prevention strategies, which is hoping to get more patients comfortable with talking with their providers about using PrEP, and then ultimately using it themselves. So, everything that we've presented today, we are also going to be putting into a manuscript that should be submitting soon, so keep your eyes peeled for that. But again, we just wanted to really demonstrate that this is such an important tool, provide just some of the basic information, and we were hoping when we were creating this presentation that we would get some answers in the literature, but it shows that there is a lot, a lot of opportunity for additional research and additional clarification, again, about the interactions, if PrEP should be continued, and how we can, again, effectively increase our communication to reduce that stigma. So, we left some time because we thought there might be some questions, so if there's any questions, we can start to take those now. But thank you all so much for listening, I really, really appreciate it. I'll encourage anybody to come up to the microphone. I'm just gonna read a couple questions that came through the chat, and I think you've already answered this, but I'm going to snap my glasses together. Here we go. And you've already kind of addressed this, but I do wanna make sure that we do read these questions, and so the viewers from home, or wherever this individual is, has an opportunity to hear the question. Is a scoping a new word for literature review utilizing AI, or how does it differ from a traditional literature review? And I know you went into that, but I'll allow you to answer that if you wouldn't mind. I think it's great, because it is. It's a specific type of literature review, and I think a lot of what I have been familiar with was, and again, a systematic, an integrative review, but the scoping review is really different because you don't necessarily even need to get into, you're not answering a specific question, or it's, again, it's different than like a meta-analysis where you're ultimately synthesizing all of this to come up with a clear answer. A scoping review is really helpful in looking at all of the literature that's out there and identifying what the studies are that are currently out there, and then really, it's good about identifying the gaps in the literature, but it's not necessarily AI. I don't know if that was the question, but again, AI is great, but it's not necessarily, it's more of a framework, and I think one of the key things, there is now a Prisma extension that literally goes through all of those steps that you can go through, which is really helpful, and then there's that framework that also explains it in detail. Perfect, thank you for that. The next question came through via text message to me, so I'm gonna kind of summarize it very quickly, and that is essentially there was a lawsuit that was filed that has worked its way through the Fifth Circuit in which it was declared that the Affordable Care Act can no longer cover PrEP, and as a result of that, it was sent back to the lower court to kind of work through. This is in June of 2024. If this ultimately makes its way to the Supreme Court, because, and they do anticipate this will, how do you think that this may translate into HIV prophylaxis and treatment that PrEP was intended to help combat? I think, I agree, that is a great question, I was unaware that they have appealed that. I would say, I think one benefit is that Truvada is the original one, and it's already become a generic prescription, so even though it might not be free under the Affordable Care Act, hopefully under your pharmacy insurance, it'll be covered due to it not being a brand name anymore, and you can do generic. I do know, like, Dyscovy, if you have pharmacy insurance and it doesn't cover, or it's super expensive, they do offer coupons, so I do think it'll still be relatively affordable. It'll be interesting to see what Aplertude's able to do, because it does cater to a specific group, but at least there is a generic option for PrEP. I think it is unfortunate, though, that we are trying to prevent HIV, and we have three medications that can do it, and they're not, I mean, some are expensive, but some are generic, so it's like, there's no true, real reason to block the coverage. I mean, I feel like it's kind of important onto a level of birth control, in a sense, like it should be covered in that, but I'm also not in the government, so. But I think also, one thing that Jake highlighted in the presentation, which I wanted to kind of highlight again, which it goes to this, it is now our most effective technique in HIV prevention. It's 99% effective, which is better than other tools we have, and it doesn't, or there's no other prevention techniques that we have for HIV drug users, for example, so it's, again, it's just a really important tool, and it's a tool that's been recognized by the CDC, by the FDA, so I think it's just figuring out, like you said, how to get it covered, but I think it's recognized as such an important tool, but thank you so much, that was a great question. I agree, and I think the PrEP community are like, I know they're a big pharma, but I do believe that they do want to help prevent HIV because they made the drug, so I think they're gonna do what they can to make sure people have the access to it. Thank you. Hi, my name's Allison, I'm a CRNA from Philadelphia. I wanted to thank you guys for highlighting this and exposing the gap in the research. I think that this is very translatable information that we should all take back to our institutions because I don't think that it's addressed well, but I was curious if you had come across any research while you were doing your work in regards to the fact that we know that HIV medications in the past has caused mutations in the virus that has caused there to be resistant to HIV medications. Is there any concern about this prophylaxis and it potentially causing more variations in the virus that would cause it to be more difficult to treat? So, I'm trying to find. That's a really good question, thank you. Yes, thank you for the question. I'm trying to find. So, both like Truvada and Descovy, one part of the medication that is a dual-like HIV medication, so the amitransinabine, HIV is known to become quickly resistant to that part of the drug, so that's why they pair it with the other ones, like the TDF or TAF, to help prevent that. I think that is a very big concern, but with PrEP prescriptions, they have to have the testing every three months, and the provider prescribing it is not allowed to prescribe another three months without a negative HIV result. So, and also with HIV, you're not gonna know immediately if you have it. It can take from 12 to 90 days for it to result. So, with that being the window for the HIV to, the latest HIV will show up is in 90 days, and the testing for PrEP continuation is 90 days. I do think it is a great way to catch it in a sense if it does start to happen. Hopefully, I don't even know what to imagine if that would happen. I think it would still be our best defense, but I think you would have to use condoms in addition, and then I think we'd kind of be at square one again with people who inject drugs. I also do know that we are currently trying to cure HIV, and we are having positive results, and they are creating newer medications for HIV. So, I think with that, hopefully we are able to prevent another mutation or a super HIV that is PrEP-resistant. But when I learned about PrEP initially, that was one of my larger concerns. But I think the fact is that it is so effective that it's using any of these tools so that it prevents the spread of it from person to person. Those are those opportunities to create mutations. So, the fact that it is, and the fact that you can get to such a high level, the concentration can get to such a high level fairly easily and continues, that I think is also really helpful. That's one thing that's great about these, the current medications, is that your therapeutic levels don't drop. So, even in theory that you miss a day or two even can be okay. So, that's one thing that's really nice is that you don't see that drop, which really is where you get at risk for those mutations. That was great. Thank you so much. I appreciate you. Yeah, of course. I actually thought of a question as you were saying that. I was curious if there's any increase in compliance or testing for high-risk individuals as a necessity of PrEP prescribing. So, that would be another thing to look at in the research as to whether or not that rate has increased and thus would also prevent further mutation as well as a. Right. I agree. I think that is a great question and probably a great way to frame it and to see if there is a compliance because if you are, in a sense, forcing people to know their status, it's definitely helping because currently one in eight in the U.S. don't know that they're infected with HIV. So, if people are getting on PrEP and having to know their status, I think it does help everybody understand what their status is and to also prevent the spread. And also with what we were saying earlier about your earlier question, I think even though hopefully PrEP is able to prevent the spread of HIV to where we can get it under control and to a sense where we don't worry about a massive outbreak because it's, so the people who are infected with HIV become such a small number. Thank you again. Thank you. And I think one of the other things we really want to highlight in this presentation is that in certain communities, we are seeing that it is becoming more prevalent to be on PrEP in some of these risky behavior communities. However, there's still a lot of opportunity and particularly, which Jake highlighted, in the South and in different populations that are seeing a big actual increase. I think African American women in particular are one of the populations that are actually seeing rates of HIV going up. So there's still other populations that could really benefit from this. So that's one of the really big reasons that we wanted to present it and just get people again more comfortable with the idea. Good morning, I'm Kimberly Lusk from Atlanta, VA, and I had a question about the Dyscove. Can you tell me why it is only prescribed for patients that are born male? I believe it's the, it's only FDA approved, but I did say we would talk about off labels. That was why we mentioned it. I think it is truly just because of when they did the initial testing population, they only tested people who were born male. So people who are male, born male now, or people who have transitioned but were biologically a male at birth. They were the cohort that they studied Dyscove on. So and because it is newer, I wonder hopefully they'll continue to study it in people who were born female, and then maybe we can get that Dyscove approved for them as well. That's a great question. And I think it's again just targeting those, the certain types of populations and then expanding it to the other groups as well. If you have any questions, please feel free to email us. And then again, look out, this will be coming out and hopefully that when we publish our results, that'll also spark additional research on this and hopefully you can all bring it back to your institutions and feel more comfortable with this medication. That's what our hope is. So thank you guys so much, we really appreciate it.

Jeff Darna

American Association of Nurse Anesthesiology

Professional Development Committee

CEUs

PrEP

HIV prevention

Truvada

Dyscovi

Apertude