Pre-exposure prophylaxis for HIV: Difference between revisions

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(updated to match Canadian guidelines)
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* Principle: give HIV meds to high-risk individuals to prevent seroconversion if exposed
*Principle: give HIV meds to high-risk individuals to prevent seroconversion if exposed
* Works when adherent, but adherence is poor
*Works when adherent, but adherence is poor


= Eligibility =
==Eligibility==


*MSM: condomless anal sex within the last 6 months, and any of:
* MSM with multiple unprotected exposures, or HIV-positive partner, or sex work
**Sexually transmitted infection within the last 12 months
* Women with high number of unprotected partners, HIV-positive parter, or sex work
**Recurrent use of [[HIV PEP]] at least twice
* People who inject drugs and share needles
**Ongoing sexual relationship with an HIV-positive partner who has a detectable viral load or is not on treatment
* However,
** If a positive partner is undetectable for 6 months, no need for PrEP
***Stop if partner is undetectable for 6 months
**High-incidence risk index (HIRI)-MSM ≥11
** People who inject drugs may not benefit as much
*Heterosexual exposure
**Ongoing condomless sexual relationship with an HIV-positive partner who has a detectable viral load or is not on treatment
***Stop if partner is undetectable for 6 months
**Can be considered even if condomless sexual relationship with an HIV-positive partner with low risk
*People who inject drugs
**Consider if they share drug paraphernalia with someone who has risk of HIV
**People who inject drugs may not benefit as much


= Process =
==Process==


== Baseline ==
===Baseline===


* HBV sAb, sAg, and cAb; HCV; and HAV, so you can vaccinate
*[[HBV]] (sAb, sAg, and cAb); [[HCV]]; and [[HAV]], so you can vaccinate
* STI screening
*STI screening
** Syphilis, chlamydia, and gonorrhea
**[[Syphilis]], [[chlamydia]], and [[gonorrhea]]
** Urethral, pharyngeal, and rectal
**Urethral, pharyngeal, and rectal
* Vaccinations
*Vaccinations
** HAV, if not immune
**[[HAV]] and [[HBV]], if not immune
** HPV, if eligible
**[[HPV]], if eligible


== Treatment ==
===Treatment===


* Tenofovir/emtricitabine 1 tablet daily for 3 months at a time, without repeats
*[[Tenofovir disoproxil fumarate]]/[[emtricitabine]] 300/200 mg daily for 3 months at a time, without repeats
* Counsel on condom use and side effects
*Counsel on condom use and side effects
** Take it for 7 days before it is effective
**Take it for 7 days before it is effective
** Connect to mental health and other services, if indicated
**Connect to mental health and other services, if indicated


== Follow-up ==
===Follow-up===


* Follow-up every 3-4 months
*Follow-up after 30 days and then every 3 months thereafter
* Ask about HIV and STI symptoms, and screen them
* Side effects of medications
* Reassess need for PrEP
* Screen for drug and alcohol abuse


{| class="wikitable"
= Further Reading =
!Item
!Baseline
!30 days
!q3mo
!q12mo
|-
! colspan="5" |Clinical Evaluation
|-
|Symptoms of HIV seroconverion
|x
|x
|x
|
|-
|PrEP adherence and side effects
|
|x
|x
|
|-
|Assess indication for PrEP
|x
|x
|x
|
|-
|Counsel on prevention of HIV and STIs
|x
|x
|x
|
|-
|Assess and manage other syndemic conditions, including drug and alcohol use
|x
|x
|x
|
|-
! colspan="5" |Laboratory Evaluation
|-
|HIV test
|x
|x
|x
|
|-
|Hepatitis A immunity
|x
|
|
|
|-
|Hepatitis B screen
|x
|
|
|if unvaccinated
|-
|Hepatitis C screen
|
|
|
|x
|-
|Screen for gonorrhea and chlamydia
|x
|
|x
|
|-
|Syphilis serology
|x
|
|x
|
|-
|CBC
|x
|
|x
|
|-
|Creatinine
|x
|x
|x
|
|-
|Urinalysis
|x
|
|
|
|-
|Pregnancy test (if appropriate)
|x
|
|x
|
|}


==Further Reading==
* Tan ''et al''. [https://doi.org/10.1503/cmaj.170494 Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis]. ''CMAJ'' 2017;189(47):e1448-e1458.

*Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. ''CMAJ'' 2017;189(47):e1448-e1458. doi: [https://doi.org/10.1503/cmaj.170494 10.1503/cmaj.170494]


[[Category:HIV]]
[[Category:HIV]]

Revision as of 10:47, 17 August 2020

  • Principle: give HIV meds to high-risk individuals to prevent seroconversion if exposed
  • Works when adherent, but adherence is poor

Eligibility

  • MSM: condomless anal sex within the last 6 months, and any of:
    • Sexually transmitted infection within the last 12 months
    • Recurrent use of HIV PEP at least twice
    • Ongoing sexual relationship with an HIV-positive partner who has a detectable viral load or is not on treatment
      • Stop if partner is undetectable for 6 months
    • High-incidence risk index (HIRI)-MSM ≥11
  • Heterosexual exposure
    • Ongoing condomless sexual relationship with an HIV-positive partner who has a detectable viral load or is not on treatment
      • Stop if partner is undetectable for 6 months
    • Can be considered even if condomless sexual relationship with an HIV-positive partner with low risk
  • People who inject drugs
    • Consider if they share drug paraphernalia with someone who has risk of HIV
    • People who inject drugs may not benefit as much

Process

Baseline

Treatment

  • Tenofovir disoproxil fumarate/emtricitabine 300/200 mg daily for 3 months at a time, without repeats
  • Counsel on condom use and side effects
    • Take it for 7 days before it is effective
    • Connect to mental health and other services, if indicated

Follow-up

  • Follow-up after 30 days and then every 3 months thereafter
Item Baseline 30 days q3mo q12mo
Clinical Evaluation
Symptoms of HIV seroconverion x x x
PrEP adherence and side effects x x
Assess indication for PrEP x x x
Counsel on prevention of HIV and STIs x x x
Assess and manage other syndemic conditions, including drug and alcohol use x x x
Laboratory Evaluation
HIV test x x x
Hepatitis A immunity x
Hepatitis B screen x if unvaccinated
Hepatitis C screen x
Screen for gonorrhea and chlamydia x x
Syphilis serology x x
CBC x x
Creatinine x x x
Urinalysis x
Pregnancy test (if appropriate) x x

Further Reading

  • Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. CMAJ 2017;189(47):e1448-e1458. doi: 10.1503/cmaj.170494
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