Evaluation of patients prior to initiation of oral pre-exposure prophylaxis (PrEP) against HIV^[1-3]

Before initiating PrEP

Determine eligibility^*

Document negative HIV test(s) (typically antigen/antibody test) within one week of starting PrEP medication
Test for acute HIV infection with HIV RNA if patient has symptoms consistent with acute HIV infection or has had a known exposure to HIV in the last 4 weeks
Confirm that patient is at ongoing, high risk for acquiring HIV infection based upon detailed sexual and drug use history and results of STI testing^*
Confirm that calculated estimated glomerular filtration rate is ≥30 mL/min/1.73 m²^¶Δ

Other tests to determine risks of PrEP

Screen for HBV^◊ and HCV^§
Obtain urinalysis in patients with risk factors for renal disease^¥
Perform DXA scan in patients with, or at high risk for, osteoporosis^‡
Obtain baseline lipid panel and weight if TAF-FTC is being considered for PrEP^†
Perform pregnancy testing for patients who could become pregnant

Beginning PrEP medication regimen

Prescribe 1 tablet of TDF-FTC or TAF-FTC daily^Δ
In general, prescribe no more than a 90-day supply, renewable only after HIV testing confirms that patient remains HIV uninfected
Provide counseling on condoms,** risk reduction for sexual and drug-using behaviors, and PrEP medication adherence

This table addresses the evaluation of patients prior to initiating oral PrEP with a tenofovir-containing regimen and should be used in conjunction with UpToDate content on PrEP.

DXA: dual-energy x-ray absorptiometry; FTC: emtricitabine; HBV: hepatitis B virus; HCV: hepatitis C virus; HIV: human immunodeficiency virus; PrEP: pre-exposure prophylaxis; STI: sexually transmitted infection.

* Some patients may request PrEP but not endorse specific risk factors for HIV acquisition. In this setting we typically administer PrEP, assuming there are no other contraindications, since some people may not feel comfortable disclosing HIV risk behaviors.

¶ Individuals with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² are not candidates for PrEP with TDF-FTC. Individuals with an eGFR <30 ml/min/1.73 m² are not candidates for PrEP with either TDF-FTC or TAF-FTC. For such persons, injectable therapy with long-acting cabotegravir can be considered.

Δ Daily TDF-FTC is our preferred oral regimen for most patients. For men who have sex with men (MSM) without chronic HBV infection, on-demand/event driven PrEP with TDF-FTC (referred to as 2-1-1) is an alternative to daily PrEP. In addition, TAF-FTC is an alternative regimen for MSM and transgender women with renal and bone issues. Refer to the UpToDate topic on PrEP for additional information on regimen selection.

◊ Vaccinate against hepatitis B if susceptible. If chronic HBV is diagnosed, patients with chronic HBV should also be managed in conjunction with a specialist in the management of HBV. Although TDF-FTC or TAF-FTC can be used for both treatment of chronic HBV and HIV prevention, there is a theoretical risk that discontinuing therapy may result in a flare of HBV.

§ Persons who inject drugs and MSM who engage in high-risk sexual behaviors are at risk for HCV infection. Patients who test positive should be referred for treatment.

¥ It is reasonable to obtain a baseline urinalysis when starting TDF-FTC in patients with risk factors for renal disease, such as hypertension, diabetes, proteinuria, and prior history of renal insufficiency. This may help inform the choice of agent (TDF-FTC versus TAF-FTC) and be used for comparison when monitoring.

‡ Refer to the topic within UpToDate that discusses risk factors for osteoporosis.

† Although lipid testing and weight are not specifically recommended by guideline panels, in clinical trials, higher rates of triglyceride elevation and weight gain were seen among men taking TAF-FTC compared with those taking TDF-FTC.

** In addition to preventing sexually transmitted infections, condoms should be encouraged until adequate levels of tenofovir are achieved in the rectal and cervicovaginal tissues (eg, 7 days in patients engaging in anal sex and 21 days for women engaging in receptive vaginal sex).

References:

Interim guidance: preexposure prophylaxis for the prevention of HIV infection in men who have sex with men. MMWR 2011; 60:65.
Interim Guidance for Clinicians Considering the Use of Preexposure Prophylaxis for the Prevention of HIV Infection in Heterosexually Active Adults. MMWR 2012; 61:586.
Preexposure Prophylaxis for the Prevention of HIV Infection in the United States (2021 Update) – Clinical Practice Guideline. United States Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf (Accessed on August 26, 2022).

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Evaluation of patients prior to initiation of oral pre-exposure prophylaxis (PrEP) against HIV[1-3]

Evaluation of patients prior to initiation of oral pre-exposure prophylaxis (PrEP) against HIV^[1-3]