Pre-exposure prophylaxis for HIV: Difference between revisions

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==Background==
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= HIV pre-exposure prophylaxis (PrEP) =
  
   
  +
*Principle: give HIV meds to high-risk individuals to prevent seroconversion if exposed
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== 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 ==
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===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
  
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**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
  
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**Recurrent use of [[HIV PEP]] at least twice
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* People who inject drugs and share needles
  
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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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* 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
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**[[HIRI-MSM|HIV incidence risk index for men who have sex with men]] (HIRI-MSM) ≥11
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** People who inject drugs may not benefit as much
  
  +
*'''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
  +
***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'''
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**Consider if they share drug paraphernalia with someone who has risk of HIV
  +
**People who inject drugs may not benefit as much
   
  +
===Baseline Investigations===
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== Process ==
  
   
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*[[HBV]] (sAb, sAg, and cAb); [[HCV]]; and [[HAV]], so you can vaccinate
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=== Baseline ===
  
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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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* HBV sAb, sAg, and cAb; HCV; and HAV, so you can vaccinate
  
−
* STI screening
  
−
** Syphilis, chlamydia, and gonorrhea
  
−
** Urethral, pharyngeal, and rectal
  
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* Vaccinations
  
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** HAV, if not immune
  
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** 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===
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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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*Follow-up after 30 days and then every 3 months thereafter
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=== Follow-up ===
  
   
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{| class="wikitable"
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* Follow-up every 3-4 months
  
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!Item
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* Ask about HIV and STI symptoms, and screen them
  
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!Baseline
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* Side effects of medications
  
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!30 days
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* Reassess need for PrEP
  
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!q3mo
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* Screen for drug and alcohol abuse
  
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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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|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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|Assess indication for PrEP
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| style="text-align:center;" |X
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| style="text-align:center;" |X
  +
| style="text-align:center;" |X
  +
|
  +
|-
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|Counsel on prevention of HIV and STIs
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| style="text-align:center;" |X
  +
| style="text-align:center;" |X
  +
| style="text-align:center;" |X
  +
|
  +
|-
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|Assess and manage other syndemic conditions, including drug and alcohol use
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| style="text-align:center;" |X
  +
| style="text-align:center;" |X
  +
| style="text-align:center;" |X
  +
|
  +
|-
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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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|[[Hepatitis A virus|Hepatitis A]] immunity
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| style="text-align:center;" |X
  +
|
  +
|
  +
|
  +
|-
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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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| style="text-align:center;" |X
  +
|-
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|Screen for [[gonorrhea]] and [[chlamydia]]
  +
| style="text-align:center;" |X
  +
|
  +
| style="text-align:center;" |X
  +
|
  +
|-
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|[[Syphilis]] serology
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| style="text-align:center;" |X
  +
|
  +
| style="text-align:center;" |X
  +
|
  +
|-
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|CBC
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| style="text-align:center;" |X
  +
|
  +
| style="text-align:center;" |X
  +
|
  +
|-
  +
|Creatinine
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| style="text-align:center;" |X
  +
| style="text-align:center;" |X
  +
| style="text-align:center;" |X
  +
|
  +
|-
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|Urinalysis
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| style="text-align:center;" |X
  +
|
  +
|
  +
|
  +
|-
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|Pregnancy test (if appropriate)
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| style="text-align:center;" |X
  +
|
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| style="text-align:center;" |X
  +
|
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|}
   
−
== 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]]
  
[[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
  • 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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