HIV Pre-exposure Prophylaxis Algorithm: Men Who Have Sex With Men
HIV Pre-exposure Prophylaxis Algorithm: Men Who Have Sex With Men
Recent findings from clinical trials have shown that daily oral antiretroviral preexposure prophylaxis (PrEP) with a fixed-dose combination of tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) in men who have sex with men (MSM), men and women in heterosexual HIV-discordant couples, and heterosexual men and women demonstrated substantial reduction in the rate of HIV acquisition. The iPrEx study showed that prophylaxis with TDF/FTC provided an average of 44% reduction in the risk of HIV acquisition among MSM and transgender women who have sex with men. The CDC has published a clinical practice guideline for PrEP use for the prevention of HIV infection in MSM, heterosexual women and men, and IV drug users.
Before initiating PrEP: Confirm patient’s serologic test is HIV negative and there are no symptoms of acute HIV infection
No
▶
PrEP not indicated; seek HIV care
Yes
▼
Confirm patient is at substantial, ongoing, high risk for acquiring HIV infection
— Treat if active infection exists, regardless of PrEP initiation
• Screen for hepatitis C virus (HCV) infection
— Treat if active infection exists
— Seek HCV care provider if needed
• Screen and treat as needed for STI’s (syphilis, gonorrhea, chlamydia)
▼
Initiate PrEP Regimen:
• Prescribe TDF/FTC 1 tablet daily for 90 days
— In general, prescribe no more than a 90-day supply, renewable only after patient is confirmed HIV-uninfected
• If active HBV infection is diagnosed, consider using TDF/FTC for both active HBV infection treatment and HIV prevention
• Provide risk-reduction and PrEP medication adherence counseling and condoms
• Every 3 months, perform an HIV antibody test; document negative result
▼
▼
Patient remains HIV negative after 3 months
Patient tests HIV positive
▼
▼
Follow-up: Evaluate and support PrEP medication adherence at each follow-up visit, more often if inconsistent adherence is identified
• At least every 3 months:
— Perform HIV testing and assess for symptoms of acute infection to document HIV-negative status
— Assess risk behaviors and provide risk-reduction counseling and condoms
— Perform STI testing in high risk patients (eg, previous STI, multiple sex partners)
• At least every 6 months:
— Assess renal function. Withhold PrEP if CrCl <60ml/min; consult with nephrologist if CrCl steadily declining (but remains ≥60 ml/min)
— Perform STI testing
• At least every 12 months:
— Evaluate for continued need for PrEP
• Discontinue PrEP if HIV infection is acquired
• Perform confirmatory HIV test. Measure CD4 count, viral load, genotypic HIV viral resistance
• Convert to HIV treatment regimen without waiting for additional test results
• Refer to experienced HIV care provider
NOTES
Key: STI = sexually transmitted infection
REFERENCES
Centers for Disease Control and Prevention: US Public Health Service. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2017 Update: A Clinical Practice Guideline. https://www.cdc.gov/hiv/pdf/guidelines/cdc-hiv-prep-guidelines-2017.pdf. Published March 2018. Accessed April 19, 2008.
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