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
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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
 +
*Works when adherent, but adherence is poor
   
−
= Eligibility =
 +
==Eligibility==
   
  +
*MSM: condomless anal sex within the last 6 months, and any of:
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* MSM with multiple unprotected exposures, or HIV-positive partner, or sex work
  
  +
**Sexually transmitted infection within the last 12 months
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* Women with high number of unprotected partners, HIV-positive parter, or sex work
  
  +
**Recurrent use of [[HIV PEP]] at least twice
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* 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
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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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***Stop if partner is undetectable for 6 months
  +
**High-incidence risk index (HIRI)-MSM ≥11
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** 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
   
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= Process =
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==Process==
   
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== Baseline ==
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===Baseline===
   
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* HBV sAb, sAg, and cAb; HCV; and HAV, so you can vaccinate
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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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*STI screening
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** Syphilis, chlamydia, and gonorrhea
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**[[Syphilis]], [[chlamydia]], and [[gonorrhea]]
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** Urethral, pharyngeal, and rectal
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**Urethral, pharyngeal, and rectal
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* Vaccinations
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*Vaccinations
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** HAV, if not immune
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**[[HAV]] and [[HBV]], if not immune
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** HPV, if eligible
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**[[HPV]], if eligible
   
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== Treatment ==
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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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*[[Tenofovir disoproxil fumarate]]/[[emtricitabine]] 300/200 mg daily for 3 months at a time, without repeats
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* Counsel on condom use and side effects
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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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**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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**Connect to mental health and other services, if indicated
   
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== Follow-up ==
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===Follow-up===
   
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* Follow-up every 3-4 months
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*Follow-up after 30 days and then every 3 months thereafter
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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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{| class="wikitable"
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= Further Reading =
  
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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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|x
  +
|x
  +
|x
  +
|
  +
|-
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|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
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|-
  +
|HIV test
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|x
  +
|x
  +
|x
  +
|
  +
|-
  +
|Hepatitis A immunity
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|x
  +
|
  +
|
  +
|
  +
|-
  +
|Hepatitis B screen
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|x
  +
|
  +
|
  +
|if unvaccinated
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|-
  +
|Hepatitis C screen
  +
|
  +
|
  +
|
  +
|x
  +
|-
  +
|Screen for gonorrhea and chlamydia
  +
|x
  +
|
  +
|x
  +
|
  +
|-
  +
|Syphilis serology
  +
|x
  +
|
  +
|x
  +
|
  +
|-
  +
|CBC
  +
|x
  +
|
  +
|x
  +
|
  +
|-
  +
|Creatinine
  +
|x
  +
|x
  +
|x
  +
|
  +
|-
  +
|Urinalysis
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|x
  +
|
  +
|
  +
|
  +
|-
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|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 06:47, 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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