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Prescribing PrEP: A Guide for Healthcare Providers

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Pre-Exposure Prophylaxis (PrEP) with daily tenofovir/emtricitabine is recommended as one HIV prevention option for all with risks of acquiring HIV infection through sex or drug use.

PrEP Indications

Consider offering PrEP to HIV-negative adults and adolescents who are at risk of HIV, including:

  • Any sex partner with HIV or HIV risk factors
  • Condomless vaginal or anal sex with a partner of
  • Unknown HIV status who is at risk of HIV infection
  • A recent bacterial sexually transmitted infection (gonorrhea/chlamydia/syphilis)
  • Injection drug use with sharing of needles/equipment
  • Any survival/transactional sex
  • Desire to conceive with a partner who is HIV-positive

Contraindications

  • HIV infection
  • Weight < 77 lbs
  • Estimated creatinine clearance (eCrCl) < 60 mL/min forTDF/FTC or < 30 mL/min for TAF/FTC
  • Possible HIV exposure within the past 72 hours, insteadoffer nPEP, then consider PrEP.
    • Clinician PEPline: (888) 448-4911

What to Prescribe

Daily PrEP

  • Tenofovir disoproxil fumarate/emtricitabine (TDF/FTC, Truvada, or generic equivalent)
    • 300 mg/200 mg, 1 tab PO daily, #30, 2 refills for a total 90-day supply

OR

  • Tenofovir alafenamide/emtricitabine (TAF/FTC or Descovy)
    • 25 mg/200 mg, 1 tab PO daily, #30, 2 refills for
    • a total 90-day supply
    •  Not to be used as PrEP by those at risk from receptive vaginal sex (e.g., cisgender women and some transgender people)

On-Demand or 2-1-1 PrEP:

Alternative for MSM who have sex infrequently (not FDA approved for vaginal receptive sex)

Truvada or generic equivalent (TDF/FTC)

  • 300 mg/200 mg, #30, 2 refills for a total 90-daysupply
  • 2-1-1 PrEP dosing:
    • 2 tabs PO taken 2-24 hours prior to having sex, then
    • 1 tab PO 24 hours after first 2 tabs taken, then
    • 1 tab PO 48 hours after first 2 tabs taken
    • Continue 1 tab PO daily until 48 hours after last sexual encounter

Cautions

  • Symptoms of possible acute HIV (e.g., flu-like illness); defer PrEP and evaluate immediately for acute HIV, including HIV RNA testing
  • Hepatitis B (HBV) infection can flare when stopping PrEPmedications; check for HBV infection before starting PrEP
  • Chronic kidney disease (CKD) or significant risk of CKD
  • Osteoporosis
  • Pregnancy or breastfeeding; discuss risks/benefits
  • Be aware of any local policies related to minors and HIVprevention/treatment

Side Effects

  • 10% of patients experience nausea, diarrhea, or headache; these are usually mild and resolve within 1 month
  • Small risk of renal dysfunction; typically reversible if PrEP isstopped (risk greater with TDF than with TAF)
  • PrEP associated with 1% loss of bone mineral density over1 year; no increased risk of fractures (less risk with TAF)
  • TAF is associated with weight gain

Lab Screening and Visits

  • Initial visit: HIV test (ideally 4th generation HIV Ag/Ab), HIV RNA (if possibly infected within the past 2-3 weeks), creatinine, gonorrhea/chlamydia (include throat, rectum, and genital/urine screening according to sites of exposure), syphilis, hepatitis A (HAV) Ab, HBV sAb/cAb/Ag, hepatitis C (HCV) Ab; pregnancy and trichomonas tests as appropriate
  • Week 1: Call, check if prescription filled, assess adherenceand side effects.
  • Month 1: (optional) Consider HIV test (ideally 4th generationHIV Ag/Ab), assess adherence and side effects
  • At least every 3 months: HIV test (ideally 4th generationHIV Ag/Ab), pregnancy test, assess adherence, evaluate the need to continue PrEP, provide 3-month refill
  • At least every 6 months: Gonorrhea/chlamydia (throat, rectum, and genital/urine screening), and syphilis. Trichomonas if appropriate. Test more frequently if athigher risk
  • Renal function: Creatinine at baseline, at 3 months, andat least every 6 months, more frequent if risk factors for kidney disease
  • At every visit: Assess for signs/symptoms of acute HIVinfection; provide risk reduction counseling
  • Provide vaccination for HAV, HBV, Human papillomavirus (HPV) as recommended

Counseling Topics

  • Importance of close adherence, link dosing to routine
  • STI and HIV prevention, i.e., condom use/risk reduction
  • Safer injection drug use practices
  • Need for regular follow-up visits and lab tests
  • Reproductive goals/contraception
  • Symptoms of acute HIV infection
  • Risks of stopping (HIV infection; flare of HBV if infectedwith HBV) and cautions for restarting (need for HIV testing,risk of inadequate treatment if HIV infected)
  • Insurance/medication assistance
  • Procedures for refills

Efficacy Key Messages

  • When taken daily with excellent adherence, PrEP is highlyeffective for preventing HIV (> 90%)
  • With daily TDF/FTC, maximum drug levels are reached inrectal tissues after 7 days and in blood and vaginal tissuesafter 20 days
  • If planning to stop daily PrEP, continue for 28 days afterlast potential HIV exposure
  • PrEP does not prevent infection with gonorrhea, chlamydia, syphilis, genital warts, herpes, or hepatitis A, B, C viruses
  • PrEP does not prevent pregnancy
  • If a potential high-risk HIV exposure occurs while NOT onPrEP, start nPEP (within 72 hours) for 28 days, then restartPrEP if still HIV Ag/Ab negative

Resources

Medication Assistance Programs

Attribution

This resource was adapted from the Cascade AIDS Project and Mountain West AETC - Oregon Program's Prescribing PrEP for HIV Prevention pocket guide and was modified for a national audience by the AETC National Coordinating Resource Center.

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