View source for Pre-exposure prophylaxis for HIV

==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
**[[HIRI-MSM|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===

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

===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

{| class="wikitable"
!Item
!Baseline
!30 days
!q3mo
!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==

*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]]