Pre-exposure prophylaxis for HIV: Difference between revisions
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+ | ==Background== |
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− | * Principle: give HIV meds to high-risk individuals to prevent seroconversion if exposed |
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− | * Works when adherent, but adherence is poor |
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+ | *Principle: give HIV meds to high-risk individuals to prevent seroconversion if exposed |
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− | = Eligibility = |
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+ | *Works when adherent, but adherence is often poor |
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+ | ==Management== |
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− | * MSM with multiple unprotected exposures, or HIV-positive partner, or sex work |
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− | * Women with high number of unprotected partners, HIV-positive parter, or sex work |
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− | * People who inject drugs and share needles |
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− | * However, |
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− | ** If a positive partner is undetectable for 6 months, no need for PrEP |
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− | ** People who inject drugs may not benefit as much |
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+ | ===Assessing Eligibility=== |
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− | = Process = |
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+ | *'''MSM:''' condomless anal sex within the last 6 months, and any of: |
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− | == Baseline == |
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+ | **Sexually transmitted infection within the last 12 months |
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+ | **Recurrent use of [[HIV PEP]] at least twice |
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+ | **Ongoing sexual relationship with an HIV-positive partner who has a detectable viral load or is not on treatment |
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+ | ***Stop if partner is undetectable for 6 months |
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+ | **[[HIRI-MSM|HIV incidence risk index for men who have sex with men]] (HIRI-MSM) ≥11 |
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+ | *'''Heterosexual exposure''' |
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+ | **Ongoing condomless sexual relationship with an HIV-positive partner who has a detectable viral load or is not on treatment |
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+ | ***Stop if partner is undetectable for 6 months |
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+ | **Can be considered even if condomless sexual relationship with an HIV-positive partner with low risk |
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+ | *'''People who inject drugs''' |
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+ | **Consider if they share drug paraphernalia with someone who has risk of HIV |
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+ | **People who inject drugs may not benefit as much |
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+ | ===Baseline Investigations=== |
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− | * HBV sAb, sAg, and cAb; HCV; and HAV, so you can vaccinate |
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− | * STI screening |
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− | ** Syphilis, chlamydia, and gonorrhea |
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− | ** Urethral, pharyngeal, and rectal |
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− | * Vaccinations |
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− | ** HAV, if not immune |
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− | ** HPV, if eligible |
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+ | *[[HBV]] (sAb, sAg, and cAb); [[HCV]]; and [[HAV]], so you can vaccinate |
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− | == Treatment == |
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+ | *STI screening |
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+ | **[[Syphilis]], [[chlamydia]], and [[gonorrhea]] |
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+ | **Urethral, pharyngeal, and rectal |
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+ | *Vaccinations |
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+ | **[[HAV]] and [[HBV]], if not immune |
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+ | **[[HPV]], if eligible |
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+ | ===Treatment=== |
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− | * Tenofovir/emtricitabine 1 tablet daily for 3 months at a time, without repeats |
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− | * Counsel on condom use and side effects |
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− | ** Take it for 7 days before it is effective |
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− | ** Connect to mental health and other services, if indicated |
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+ | *First-line, continuous: [[tenofovir disoproxil fumarate]]/[[emtricitabine]] 300 mg/200 mg daily |
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− | == Follow-up == |
||
+ | *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 |
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+ | *Continuous prophylaxis should be prescribed for 3 months at a time without repeats, with follow-up every 3 months to give a new prescription |
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+ | *Connect to mental health and other services, if indicated |
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+ | *For continuous PrEP, wait 7 days before condomless sex if topping or 2 to 3 weeks if bottomming |
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+ | **Counsel on condom use and side effects |
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− | + | ===Follow-Up=== |
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− | * Ask about HIV and STI symptoms, and screen them |
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− | * Side effects of medications |
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− | * Reassess need for PrEP |
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− | * Screen for drug and alcohol abuse |
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+ | *Follow-up after 30 days and then every 3 months thereafter |
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− | = Further Reading = |
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+ | {| class="wikitable" |
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− | * 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. |
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+ | !Item |
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+ | !Baseline |
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+ | !30 days |
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+ | !q3mo |
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+ | !q12mo |
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+ | |- |
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+ | ! colspan="5" |Clinical Evaluation |
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+ | |- |
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+ | |Symptoms of HIV seroconverion |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |- |
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+ | |PrEP adherence and side effects |
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+ | | |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |- |
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+ | |Assess indication for PrEP |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |- |
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+ | |Counsel on prevention of HIV and STIs |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |- |
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+ | |Assess and manage other syndemic conditions, including drug and alcohol use |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |- |
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+ | ! colspan="5" |Laboratory Evaluation |
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+ | |- |
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+ | |[[HIV]] test |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |- |
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+ | |[[Hepatitis A virus|Hepatitis A]] immunity |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | | |
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+ | | |
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+ | |- |
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+ | |[[Hepatitis B virus|Hepatitis B]] screen |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | | |
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+ | |if unvaccinated |
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+ | |- |
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+ | |[[Hepatitis C virus|Hepatitis C]] screen |
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+ | | |
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+ | | |
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+ | | |
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+ | | style="text-align:center;" |X |
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+ | |- |
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+ | |Screen for [[gonorrhea]] and [[chlamydia]] |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |- |
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+ | |[[Syphilis]] serology |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |- |
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+ | |CBC |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |- |
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+ | |Creatinine |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |- |
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+ | |Urinalysis |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | | |
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+ | | |
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+ | |- |
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+ | |Pregnancy test (if appropriate) |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |} |
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+ | |||
+ | ==Further Reading== |
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+ | |||
+ | *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] |
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[[Category:HIV]] |
[[Category:HIV]] |
Latest revision as of 22:27, 1 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
- Ongoing condomless sexual relationship with an HIV-positive partner who has a detectable viral load or is not on treatment
- 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