Please note this is a Suggested Progress Note Only

Subjective:

@NAME@ is a @AGE@ @SAAB@ who is here to discuss Pre-Exposure Prophylaxis (PrEP) for prevention of HIV infection.

Reason for evaluation: {Reasons for PrEP:53903}

Risk Behavior Assessment:

In the past 6 months:

Have you had sex with men, women, or both? {Sex:53765}

How many people have you had sex with? {NUMBER:19230}

How often do you have vaginal or anal sex when neither you nor your partner wore a condom? ***

How many of your sex partners were HIV-positive? {NUMBER:19230}

With these HIV-positive partners, how often have you had vaginal or anal sex without a condom? {NUMBER:19230}

IV Drug Use: {YES:18445}

Needle sharing: {IV Drug Use:53947}

Presence of symptoms concerning for Acute HIV infection:

{ACUTEHIVSYMPTOMS:53766}

Symptoms of STI:

{STI Symptoms:53899}

PrEP Eligibility Criteria:

1.    Patient is HIV negative and no clinical signs of infection: {YES:18445}

2.    Patient is NOT in a monogamous relationship with a HIV negative partner (recently tested): {true false:53952}

Plus ONE of the following:*

3.    For MSM, any anal sex without condoms: {YES:18445}

4.    Infrequent condom use with partner at high risk for HIV infection: {YES:18445}

5.    Ongoing relationship with HIV-positive partner without undetectable viral load: {YES:18445}

6.    Infection with gonorrhea, syphilis, or, for MSM, chlamydia in the past 6 months: {YES:18445}

7.    IV drug use with needle sharing

Based on the above assessment, the patient {Is:31570} at high risk for HIV infection and PrEP {Is:31570} indicated by CDC guidelines.

*High risk behavior as an indication for PrEP also includes anticipated future high risk behavior.

Lab Results:

@RESUFAST(HIV12ABAGSCR,HEPBSURFAB,HEPBSURFAC,HEBBEAG,CHLAMYDIANAA,GONOCOCCUSNA,SYPHILISTOT,RPRQN)@

@RESUFAST(CREATININE,CRCLEARANCE,EGFR)@

@RESUFAST(ALT,AST,GGT,ALKALINEPH,BILIRUBINT)@

Review of Systems

10-point review of systems is *** except for as indicated in the History of Present Illness and {ros master:310782}

Physical Exam:

@PHYSICALEXAM@

ASSESSMENT AND PLAN

Suggested Diagnoses (Add as diagnosis and delete)***:

Contact with and (suspected) exposure to HIV (Z20.6)

Suggested Visit Codes (delete from note before signing)***:

99401: Prevention Counseling ~15 minutes

99402: Prevention Counseling ~30 minutes

99403: Prevention Counseling ~45 minutes

99404: Prevention Counseling ~60 minutes

SUGGESTED FOLLOW UP:

1.    If no recent HIV screen, order HIV 1/2 Ab Ag Screen

2.    If no recent BMP, order BMP to verify CrCl >60 mL/min

3.    Hepatitis panel and Hepatitis B surface antibody, vaccinate for Hepatitis B if not immune

4.    Pregnancy test in people who can become pregnant

5.    Once laboratory testing has resulted, prescribe 90 day supply of Descovy (preferred*) or Truvada.**

6.    Schedule 3 month follow up

*Descovy (TAF) has been shown to have lower rates of renal toxicity than Truvada (TDF), and is a preferred agent

**PrEP for the prevention of HIV is grade A recommendation by the USPTF. This medication should be covered at no cost (no co-pay or deductible) with most insurers.

Patient Counseling:

I spent *** minutes in face to face with @NAME@ discussing the risks, benefits, limitations, possible complications, dosing, importance of adherence, and required conditions for continued prescribing of PrEP. @caphe@ voiced understanding and wishes to proceed.

Anticipatory Guidance:

As we discussed today, Pre-Exposure Prophylaxis (PrEP) has the ability to significantly lower your risk of HIV infection.

Please go to any laboratory to complete your blood work in order to check your HIV status and kidney function. If these results are normal, we will prescribe the medication Descovy or Truvada for PrEP.

When taken consistently, PrEP is extremely effective in preventing HIV infection in patients at high risk. PrEP failure is almost always related to missing doses of the medication.

The medication used for PrEP is called Truvada (emcitritabine/tenofovir) or Descovy (emcitritabine/tenofovir) which is a pill taken once every day.

Common side effects of Truvada or Descovy include nausea, headache, and decreased weight. These symptoms typically go away during the first month of starting PrEP.

Rare but more serious side effects of Truvada or Descovy include the following:

Kidney problems: For this reason, we will do occasional lab tests to check your kidney function.

Liver problems: Let your provider know if you are having any of the following symptoms: skin or the white part of your eyes turns yellow, dark "tea-colored" urine, light-colored stools, loss of appetite for several days or longer, or stomach-area pain.

Bone problems: Studies show Truvada or Descovy can decrease bone density by about 0.8-1%, but this has not been shown to increase risk of fractures. If you have a higher risk of osteoporosis, we may consider occasional monitoring of bone density.

While PrEP is very effective in preventing HIV, it does not decrease the risk of other Sexually Transmitted Infections (STIs). If you are having symptoms concerning for a STI such as penile or vaginal discharge, dysuria (pain/burning with urination), ulcers, or pain near your rectum, please call the office so that we can order appropriate STI testing.

Please follow-up in the clinic in 3 months to repeat HIV testing and recheck your kidney function.