Pre-exposure prophylaxis for HIV: Difference between revisions

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==Background==
= HIV pre-exposure prophylaxis (PrEP) =


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


==Management==
* Give HIV meds to high-risk individuals to prevent seroconversion if exposed
* Works when adherent, but adherence is poor


== Eligibility ==
===Assessing 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
**[[HIRI-MSM|HIV incidence risk index for men who have sex with men]] (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


===Baseline Investigations===
== Process ==


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


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


*First-line, continuous: [[tenofovir disoproxil fumarate]]/[[emtricitabine]] 300 mg/200 mg daily
=== Treatment ===
*Alternative, continuous: [[tenofovir alafenamide]]/[[emtricitabine]] 25 mg/200 mg PO daily, if they can afford it
*Alternative, on-demand (2-1-1): [[tenofovir disoproxil fumarate]]/[[emtricitabine]] 300 mg/200 mg two pills taken 2 to 24 hours before first exposure and continued daily until 48 hours after last exposure
*Continuous prophylaxis should be prescribed for 3 months at a time without repeats, with follow-up every 3 months to give a new prescription
*Connect to mental health and other services, if indicated
*For continuous PrEP, wait 7 days before condomless sex if topping or 2 to 3 weeks if bottomming
**Counsel on condom use and side effects


===Follow-Up===
* Tenofovir/emtricitabine 1 tablet 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 after 30 days and then every 3 months thereafter
=== Follow-up ===


{| class="wikitable"
* Follow-up every 3-4 months
!Item
* Ask about HIV and STI symptoms, and screen them
!Baseline
* Side effects of medications
!30 days
* Reassess need for PrEP
!q3mo
* Screen for drug and alcohol abuse
!q12mo
|-
! colspan="5" |Clinical Evaluation
|-
|Symptoms of HIV seroconverion
| style="text-align:center;" |X
| style="text-align:center;" |X
| style="text-align:center;" |X
|
|-
|PrEP adherence and side effects
|
| style="text-align:center;" |X
| style="text-align:center;" |X
|
|-
|Assess indication for PrEP
| style="text-align:center;" |X
| style="text-align:center;" |X
| style="text-align:center;" |X
|
|-
|Counsel on prevention of HIV and STIs
| style="text-align:center;" |X
| style="text-align:center;" |X
| style="text-align:center;" |X
|
|-
|Assess and manage other syndemic conditions, including drug and alcohol use
| style="text-align:center;" |X
| style="text-align:center;" |X
| style="text-align:center;" |X
|
|-
! colspan="5" |Laboratory Evaluation
|-
|[[HIV]] test
| style="text-align:center;" |X
| style="text-align:center;" |X
| style="text-align:center;" |X
|
|-
|[[Hepatitis A virus|Hepatitis A]] immunity
| style="text-align:center;" |X
|
|
|
|-
|[[Hepatitis B virus|Hepatitis B]] screen
| style="text-align:center;" |X
|
|
|if unvaccinated
|-
|[[Hepatitis C virus|Hepatitis C]] screen
|
|
|
| style="text-align:center;" |X
|-
|Screen for [[gonorrhea]] and [[chlamydia]]
| style="text-align:center;" |X
|
| style="text-align:center;" |X
|
|-
|[[Syphilis]] serology
| style="text-align:center;" |X
|
| style="text-align:center;" |X
|
|-
|CBC
| style="text-align:center;" |X
|
| style="text-align:center;" |X
|
|-
|Creatinine
| style="text-align:center;" |X
| style="text-align:center;" |X
| style="text-align:center;" |X
|
|-
|Urinalysis
| style="text-align:center;" |X
|
|
|
|-
|Pregnancy test (if appropriate)
| style="text-align:center;" |X
|
| style="text-align:center;" |X
|
|}


== Further Reading ==
==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]]

Latest revision as of 02:27, 2 April 2023

Background

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

Management

Assessing 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
    • HIV incidence risk index for men who have sex with men (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

Baseline Investigations

Treatment

  • First-line, continuous: tenofovir disoproxil fumarate/emtricitabine 300 mg/200 mg daily
  • Alternative, continuous: tenofovir alafenamide/emtricitabine 25 mg/200 mg PO daily, if they can afford it
  • Alternative, on-demand (2-1-1): tenofovir disoproxil fumarate/emtricitabine 300 mg/200 mg two pills taken 2 to 24 hours before first exposure and continued daily until 48 hours after last exposure
  • Continuous prophylaxis should be prescribed for 3 months at a time without repeats, with follow-up every 3 months to give a new prescription
  • Connect to mental health and other services, if indicated
  • For continuous PrEP, wait 7 days before condomless sex if topping or 2 to 3 weeks if bottomming
    • Counsel on condom use and side effects

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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