| Before initiating PrEP |
| Determine eligibility* |
| Document negative HIV test(s) immediately before starting PrEP medication |
| Test for acute HIV infection with HIV RNA if patient has symptoms consistent with acute HIV infection or has had a high-risk exposure in the last 4 weeks |
| Confirm that patient is at substantial, ongoing, high risk for acquiring HIV infection based upon detailed sexual and drug use history and results of STI testing |
| Confirm that calculated estimated glomerular filtration rate is ≥30 mL/min/1.73 m2¶Δ |
| Other recommended tests to determine risks of PrEP |
| Screen for HBV◊ and HCV§ |
| Obtain urinalysis in patients with risk factors for renal disease¥ |
| Perform DXA scan in patients with, or at high risk for, osteoporosis‡ |
| Perform pregnancy testing for patients who could become pregnant |
| Beginning PrEP medication regimen |
| Prescribe 1 tablet of TDF-FTC or TAF-FTC dailyΔ |
| In general, prescribe no more than a 90-day supply, renewable only after HIV testing confirms that patient remains HIV uninfected |
| Provide counseling on condoms,† risk reduction, and PrEP medication adherence |
PrEP: pre-exposure prophylaxis; HIV: human immunodeficiency virus; STI: sexually transmitted infection; HBV: hepatitis B virus; HCV: hepatitis C virus; DXA: dual-energy x-ray absorptiometry; FTC: emtricitabine; eGFR: estimated glomerular filtration rate.
* Refer to the UpToDate topic on patient evaluation for pre-exposure prophylaxis for discussions of HIV testing and how to assess high-risk HIV behaviors.
¶ Individuals with an eGFR <30 ml/min/1.73 m2 are not candidates for PrEP with either TDF-FTC or TAF-FTC. Individuals with an eGFR <60 mL/min/1.73 m2 are not candidates for PrEP with TDF-FTC.
Δ TDF-FTC is our preferred regimen for most patients. TAF-FTC is an alternative therapy for PrEP for men who have sex with men and transgender women with renal and bone issues. Refer to the UpToDate topic that discusses administration of PrEP for additional information on regimen selection.
◊ Vaccinate against hepatitis B if susceptible. If chronic HBV is diagnosed, TDF-FTC or TAF-FTC can be used for both treatment of chronic HBV and HIV prevention; however, there is a theoretical risk that discontinuing therapy may result in a flare of HBV. Thus, patients with chronic HBV should also be referred to a specialist with an expertise in the management of HBV.
§ Persons who inject drugs and men who have sex with men who engage in high-risk sexual behaviors are at risk for HCV infection. Patients who test positive should be referred for treatment.
¥ Risk factors for renal disease include hypertension, diabetes, proteinuria, and prior history of renal insufficiency.
‡ Refer to the topic within UpToDate that discusses risk factors for osteoporosis.
† In addition to preventing sexually transmitted infections, condoms should be encouraged until adequate levels of tenofovir are achieved in the rectal and cervicovaginal tissues (7 days in patients engaging in anal sex and 21 days for women engaging in receptive vaginal sex).