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PrEP: A Provider’s Guide

A quick reference guide and resources for providers on prescribing and managing pre-exposure prophylaxis (PrEP) for HIV.

by Rachel K. Scott, MD, MPH, FACOG and Jeannie M. Folan, MD

published 01/09/20

Pre-exposure prophylaxis or “PrEP” with oral Tenofovir/Emtricitabine (Truvada®) can reduce transmission of HIV by up to 99% when taken daily—making PrEP a highly effective tool for preventing HIV. Unlike condoms and post-exposure prophylaxis (PEP), PrEP is controlled autonomously by the user and is in place at the time of potential HIV exposure—removing barriers of partner negotiation and disruption of a sexual act. Just as we screen patients for pregnancy desires and contraceptive use, we should inquire about our patients’ risk factors for HIV, educate them about PrEP, and offer PrEP to all patients at risk for HIV.

Even though PrEP offers the potential for enormous reduction in transmission of HIV, current data shows that it is underutilized by women. While almost 20% of new HIV diagnoses in the United States are among women, they represent only 2-3% of PrEP users. Potential barriers to women starting PrEP include lack of knowledge of PrEP among women, stigma, lack of support from social networks or significant other, and discomfort discussing high risk sexual behaviors with healthcare providers. The good news is that studies suggest that with education about PrEP, women believe PrEP is safe, effective, and desirable. Women are more likely to initiate PrEP if it is recommended by a health care provider, indicating that provider support is critical for access to and motivation to start PrEP. We can increase use of this important HIV prevention tool by engaging patients in conversations about their risk for HIV, providing education about PrEP and HIV prevention, and offering PrEP to all at-risk patients.

Here are the details you need to offer PrEP to your patients:

Who is a candidate for PrEP?

PrEP is for HIV-negative patients who in the last 6 months had:

  • Any sex partner with HIV or HIV risk factors
  • Condomless vaginal or anal sex with a partner of unknown HIV status
  • A bacterial sexually transmitted infection
  • Injection drug use
  • Used Post Exposure Prophylaxis (PEP)

PrEP should not be given to anyone who is HIV-positive or has signs or symptoms of acute HIV (flu-like symptoms, lymphadenopathy, or rash) because Truvada alone would not be adequate treatment for HIV infection and may lead to antiretroviral resistance. Per the CDC Clinical Practice Guidelines for PrEP, if someone has possible HIV exposure within the last 72 hours, offer PEP instead. After completing a 28-day course of PEP and repeat HIV screening, PrEP can be started immediately for continued protection.

Counseling tips

  • Advise patients that per FDA guidelines, it takes PrEP 20 days to reach protective levels in vaginal tissue, or 7 days in rectal tissue.
  • Side effects of PrEP are generally mild and short lived. Roughly 10% of patients experience “start-up syndrome,” which causes nausea and headache upon initiation of PrEP. These symptoms typically resolve within a month.
  • Missed doses should be taken as soon as the patient remembers. If it is almost time for the next dose, patients should skip the missed dose and take the following one as scheduled.
  • PrEP is most effective when taken daily. There is some “forgiveness” for missed doses, however PrEP leaves vaginal tissue faster than colorectal tissue, so daily adherence is especially important for people who are at risk for HIV exposure through receptive vaginal intercourse.
  • There is also a small risk of elevation in serum creatinine, which is reversible once PrEP is stopped. Because of this, PrEP should not be considered for patients with an estimated creatinine clearance of less than 60 ml/min.
  • While PrEP is associated with a 1% loss of bone mineral density, there is no evidence demonstrating an increased risk of fracture.

Prescribing, Labs, and Follow-up

Provide eligible patients with a 1-week or 1-month prescription of Truvada® (tenofovir/emtricitabine 300mg/200g) 1 tab PO daily. Due to the risk of undetected HIV at the first visit, schedule the first follow-up at a short interval to provide a refill, counseling, and repeat an HIV test—details of the components of each visit are referenced in the chart below, based on 2017 CDC Clinical Practice Guideline for PrEP.

Paying for PrEP

Most public and private insurers cover PrEP. For those in need of financial assistance, Gilead Sciences has a PrEP medication assistance program.

Discontinuing PrEP

Patients may choose to discontinue PrEP because of lower HIV risk, intolerable side effects, or inability to take a daily pill. Once stopped, protection will decrease over 7-10 days, and other methods of HIV prevention should be discussed. Patients should be made aware of post-exposure prophylaxis (PEP) and how to access it. For patients who have Hepatitis B, they may experience a flare after discontinuing PrEP and should be monitored closely.

Bottom Line

PrEP is a safe, effective, and autonomous method of HIV prevention and health care providers have a unique opportunity to do our part in ending the HIV epidemic by routinely and non-judgmentally offering PrEP to HIV-negative patients with risk factors for HIV.

Other Resources:

Rachel Scott is an OB/GYN at MedStar Washington Hospital Center and MedStar Health Research Institute. Both her clinical work and research focus on improving health and healthcare for women living with HIV and HIV prevention for women. When not hard at work, she enjoys yoga, cooking, and spending time with her husband, kiddo, and pup. Jeannie M. Folan, MD is a resident at UCHealth Fort Collins Family Medicine Residency at Poudre Valley Hospital in Colorado. She is particularly passionate about preventative healthcare for women, as well as adolescent health. She also loves bluegrass music and getting out into the mountains of Colorado to ski or bike.
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