HIV PrEP: Men Who Have Sex with Men 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 No ▶ PrEP not indicated; seek HIV care  
     
  Yes    
  ▼  
  Confirm patient’s calculated CrCl ≥60mL/min (via Cockcroft-Gault formula) No ▶ Seek physician counseling  
     
  Yes    
  ▼  
  Other recommended actions:

• Screen for hepatitis B virus (HBV) infection

— Vaccinate if susceptible

— 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.

(Rev. 4/2018)

This article originally appeared on MPR

Topics:

Infectious Disease