How to incorporate HIV PrEP into your practice
These recommendations and resources can help make HIV pre-exposure prophylaxis an essential part of your work.
PRACTICE RECOMMENDATIONS
› Actively screen and identify HIV-negative patients who are a candidate for pre-exposure prophylaxis (PrEP); commit to talking to the most easily identifiable subsets of these patients, such as men who have sex with men and transgender patients. B
› Recognize that PrEP is indicated for patients who: are sexually active with inconsistent condom use and multiple recent sex partners; have recently been given a diagnosis of a sexually transmitted infection; or have a sexual or injection partner known to be HIV-infected. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
What to tell patients. Tell patients that within the first weeks of starting PrEP, they might experience a start-up syndrome that typically manifests as gastrointestinal symptoms, headache, and fatigue. These symptoms usually resolve without the need to discontinue the medications.25
Any other concerns about PrEP?
When PrEP was first approved by the FDA, many physicians raised concern about the possibility that PrEP use would lead to increased community-level HIV drug resistance and that behavioral disinhibition might diminish the benefit of PrEP and lead to rampant STIs.26 To date, these fears have not been borne out.
Acquired drug resistance, which happens after a person becomes HIV-positive, is a real concern, particularly among people who are screened with antibody-only HIV tests that cannot detect HIV in the so-called window period and who then start PrEP during acute HIV infection. If a person is truly HIV-negative when he (she) starts PrEP, the risk of either acquired or transmitted HIV drug resistance is low and is far outweighed by the preventive benefit of PrEP.27
Similarly, there is a suggestion that syphilis infection is increasing among HIV-negative MSM due to decreased HIV-related stigma and increased mixing between HIV-negative and HIV-positive people. The evidence that PrEP has led to an increase in STI rates28 is mixed, however, and is confounded by temporal increases in STI rates and increased detection of asymptomatic STIs among people on PrEP as a result of regular screening.29
Who pays for PrEP?
The cost of PrEP medications and associated clinical care is covered by nearly all private, employer, and public health insurance. Prior authorization might be required to ensure that testing has excluded HIV infection before prescribing and then refilling prescriptions.
Continue to: For patients who have health insurance...
