Evaluation for PrEP: Assessing risk for acquiring HIV

Sexual risk behaviors*

To determine if a patient is at risk of acquiring HIV through sexual transmission, clinicians should assess sexual risk behaviors over the last 6 months.

Providers should assess the following:

The HIV status and risk behaviors of the patient's sex partners, if available.
If the patient is in a monogamous relationship with someone living with HIV, the viral suppression status of the partner.
If the patient has had condomless penile-anal or penile-vaginal sex with partners other than their main partner.
The number of sexual partners.
If the patient has a history of any bacterial STIs.

Sexually transmitted infections

STI testing should be performed in patients who are considering PrEP, even in the absence of symptoms.^¶

Providers should test for the following:

Serologic testing for syphilis, including confirmation of seroreactive results.
Nucleic acid amplification testing for gonorrhea and chlamydia at relevant mucosal sites (based on sexual history).^Δ
Assessment of hepatitis B serostatus (HBsAg, anti-HBc, anti-HBs) and hepatitis C serostatus.

Drug-using behaviors

To assess a patient's risk for HIV acquisition through parenteral and other drug use, clinicians should ask about their drug use history over the last 6 months.

This includes:

Injecting heroin, fentanyl, cocaine, and/or methamphetamine.
Sharing needles or equipment.
Using nonparenteral drugs during sex (particularly methamphetamine).^◊

Clinicians should discuss PrEP with all sexually active adolescents and adults. This table should be used to assess the risk of HIV acquisition to help inform suitability for PrEP.

PrEP: pre-exposure prophylaxis; STI: sexually transmitted infection; HBsAg: hepatitis B surface antigen; anti-HBc: hepatitis B core antibody; anti-HBs: hepatitis B surface antibody.

* It is important that the clinician ask about the patient's sexual behaviors with both main and casual partners. Although some studies have reported a higher number of transmissions from casual partners, some HIV transmissions among men who have sex with men (MSM) have been from a main partner. It is also important to understand the context of different social and situational factors (eg, does the patient have discussions about HIV status with their partners or does the patient have anonymous partners of unknown HIV status). Several online resources (eg, the Fenway National Center for LGBTQIA+, the Ready, Set, Go guidelines, the CDC website) are available to help guide providers in obtaining an HIV risk assessment.

¶ Relying on self-reported risk alone may not be sufficient to make an informed decision about PrEP initiation; the presence of certain STIs (eg, syphilis, anogenital gonorrhea, rectal chlamydia) have been highly associated with HIV acquisition and are indications for PrEP.

Δ Screening for bacterial vaginosis, Mycoplasma genitalium, and trichomonas is not routinely performed as part of the work-up before initiating PrEP since these infections have not had as strong an association with HIV. However, their presence suggests that recent condomless sex has occurred and should lead the clinician to ask about number of partners and potential risks of partners and discuss PrEP.

◊ Certain nonparenteral drugs, such as methamphetamines, can decrease the likelihood of using condoms and increase the number of sexual partners.

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Evaluation for PrEP: Assessing risk for acquiring HIV