PrEP

• related: ID

• Pre-exposure prophylaxis (PrEP) with antiretroviral medication is recommended in select persons at high risk for exposure to HIV to reduce the risk of infection.
• A two-drug combination of tenofovir disoproxil fumarate and emtricitabine, taken once daily, is FDA approved for HIV PrEP; it has been shown to be effective in reducing infection in persons at high risk.
• Effectiveness is greater than 90% in those with proven adherence.
• Additionally, once-daily tenofovir alafenamide and emtricitabine is approved for HIV PrEP, excluding in women who have receptive vaginal sex (effectiveness has not been established in this population).
• The US Preventive Services Task Force has identified specific groups of persons at high risk of HIV infection, including men who have sex with men (MSM), persons at risk through heterosexual contact, and persons who inject drugs. Persons at very high risk for HIV infection in whom PrEP is recommended have one or more of the following characteristics: a serodiscordant sex partner; inconsistent use of condoms during receptive or insertive anal sex (MSM) or with a heterosexual partner whose HIV status is unknown or is at high risk; syphilis, gonorrhea, or chlamydia infection within the past 6 months for MSM; or syphilis or gonorrhea infection within the past 6 months for heterosexual women. An additional indication for PrEP is the shared use of drug injection equipment. PrEP is also indicated in persons who engage in transactional sex or who are trafficked for sex work, men who have sex with men and women, and transgender persons if any high-risk sexual characteristics or behaviors are present. Transgender women are at especially high risk of infection.
• Patients should also be counseled on the need to continue barrier precautions, on medication toxicity, and on continued risk for other sexually transmitted infections (STIs).
• Testing should be performed for HIV, hepatitis B virus (HBV), kidney function, and pregnancy before PrEP initiation; monitoring for HIV, other STIs, and pregnancy every 3 months and performing kidney function assessment every 6 months are also recommended during PrEP therapy.
• Persons taking PrEP who test positive for HIV should have a third drug (either ritonavir-boosted darunavir or dolutegravir) added to the two-drug PrEP regimen pending results of HIV RNA and viral resistance testing. The evidence is conflicting concerning potentially increased high-risk behavior and incidence of other STIs in PrEP users during therapy. PrEP has also been calculated to have favorable cost effectiveness, well below that for other accepted preventive health measures.