Sexual History Taking 101: How Do I Start the Conversation with My Patients? | HIV Pre-Exposure Prophylaxis (PrEP) – Who’s it for? | Initial Visit, Dosing, and Follow Up | The PrEP Guidelines Center | Implement and Maintain a PrEP Program in Your Clinic | Downloadable Infographics
Review the latest recommendations with
Jonathan Shuter, MD, a Professor of Medicine in the Division of Infectious Diseases at Montefiore Medical Center and the Albert Einstein College of Medicine
Uriel Felsen, MD, an Associate Professor of Medicine in the Division of Infectious Diseases at Montefiore Medical Center and the Albert Einstein College of Medicine
Raffaele M. Bernardo, DO, an Assistant Professor of Medicine in the Division of Infectious Diseases at Montefiore Medical Center and the Albert Einstein College of Medicine
SUMMARY:
The Centers for Disease Control and Prevention (CDC) makes recommendations for the use of PrEP as biomedical HIV prevention. Based on a systematic review of the literature, these evidence-based guidelines offer a practical approach to identifying patients who would be appropriate candidates for PrEP, ordering relevant tests and laboratory procedures, and how to conduct initial and follow-up visits for patients. Given the evolving nature of PrEP research, these recommendations will be revised and updated for clinical practice on a regular basis. This section will also review other supportive guidelines and statements from ACOG and USPSTF
General Guidelines for PrEP
Safety and Efficacy
PrEP, when used as indicated, has been determined to be safe and effective in the prevention of HIV transmission among diverse populations and should be a consideration to anyone who is sexually active, including:
- Men who have sex with men and transgender women: 92% to 100% reduction in HIV transmission in clinical trials and real-world analysis
- Heterosexual women and men – 63% to 93% reduction in HIV transmission
- Persons who Inject Drugs (PWID) – 73.5% reduction in HIV transmission
- Adolescents who weigh over 35kg – over 95% reduction in HIV transmission
Eligibility
The United States Prevention Services Task Force (USPSTF) recommends offering PrEP with effective antiretroviral therapy to persons at high risk of HIV acquisition
- FDA approved oral formulation is one pill taken once a day or intramuscular injection is once very eight weeks
- Either F/TDF 200/300mg (Truvada) or F/TAF 200/25 (Descovy) are currently approved for oral use and cabotegravir is approved for intramuscular use
- Insurance must provide medication coverage for preventive services with Grade A recommendation
CDC Guidelines for Screening Eligibility
- The CDC recommends that providers should
Inform all sexually active adults and adolescents that PrEP can protect them from getting HIV
Note: We caution against seeing patients as levels of “risk,” particularly when it comes to sexual health | What it involves is taking a good sexual history and documenting what behavioral choices they make, then offering PrEP as an option for HIV prevention
- PrEP is for people without HIV who could be exposed to HIV from sex or injection drug use
- CDC recommends the following should be assessed for PrEP including
- Sexually active gay and bisexual men without HIV
- Sexually active heterosexual men and women without HIV
- Sexually active transgender persons without HIV
- Persons without HIV who inject drugs
- Persons who have been prescribed non-occupational post-exposure prophylaxis (PEP) and report behaviors that could expose them to HIV, or who have used multiple courses of PEP
- For sexually active adults and adolescents
- Anal or vaginal sex in the past six months and
- HIV-positive sexual partner (especially if partner has unknown or detectable viral load) or
- Recent bacterial STI or
- History of inconsistent or no condom use with sexual partner(s)
- For persons who inject drugs
- HIV-positive injecting partner or
- Shares drug preparation or injection equipment
- All persons eligible for PrEP
- Documented negative HIV test result before prescribing PrEP and
- No signs/symptoms of acute HIV infection and
- Normal renal function and
- No contraindicated medications
Note: While the CDC compartmentalizes “risk groups” as listed above, clinicians should remember that sexual health does not fit neatly into static compartments | Sexuality and sexual behavior are fluid, and individuals may change their partners, behavior, and condom use over time and situations
Other Considerations
Follow-up
- Patients taking PrEP can be followed closely by medical staff who are both clinical and non-clinical to assure proper usage and safety
- Current recommended follow-up every three months for oral PrEP or every two months for intramuscular PrEP
- Use of in-person and telemedicine visits
- Specific laboratory testing is indicated upon initial visit and subsequent follow-up
Women’s Health
The American College of Obstetricians and Gynecologists (ACOG) recommends providers working with women at risk of HIV transmission be aware and up to date on this preventative health tool and encourage strong adherence as key to its effectiveness
Future Directions
- Future delivery systems of PrEP are in various stages of clinical development and research and will likely become available as options in the future:
- Long acting injectables – now FDA approved!
- Implants
- Long-acting oral agents
- Patches
Learn More – Primary Sources:
CDC Guidelines Pre-Exposure Prophylaxis
National Clinician Consulting Center: PrEP: Pre-Exposure Prophylaxis
National Institute of Health (NIH): Pre-Exposure Prophylaxis (PrEP)
World Health Organization (WHO) compendium of PrEP publications
ACOG: Preexposure Prophylaxis for the Prevention of Human Immunodeficiency Virus
Commercial Support
This educational activity is supported by an independent educational grant from Gilead Sciences
Faculty Disclosures
Dr. Shuter has no relevant financial relationships to disclose
Dr. Felsen has no relevant financial relationships to disclose
Dr. Bernardo has no relevant financial relationships to disclose
Special Thanks
Special thanks to David Malebranche, MD, MPH and Ariel Watriss, MSN, NP for their insights and contribution.