Pre-exposure prophylaxis (PrEP) for HIV

Question 1

Who is eligible?

Answer 1

Usually available from local sexual health clinic.

Eligible for funded PrEP

Pt tested HIV negative within the last 2 weeks and either: all of the following:

1. is male or transgender
2. has sex with men
3. is likely to have multiple episodes of condomless anal intercourse in the next 3 months, and in the past 3 months, has any of:

• had condomless receptive anal intercourse with 1 or more casual partners
• been diagnosed with rectal chlamydia, rectal gonorrhoea, or infectious syphilis
• used methamphetamin

4. pt has a regular partner who is HIV positive
5. the partner is either not on treatment or has a detectable viral load (> 200 copies/mL)
6. condoms have not been consistently used.

Question 2

What do you need to check prior to starting PrEP

Answer 2

Check for risk factors for renal disease

Eg diabetes, hypertension, smoking, concurrent medications, and known history of renal impairment.

In PrEP studies, tenofovir use has not been associated with significant renal problems

Some pts may be at higher risk while taking emtricitabine/ tenofovir fixed-dose combination.

• Take blood pressure.
• Blood tests – HIV serology, syphilis serology, hepatitis A, hepatitis B, hepatitis C, creatinine, eGFR, LFTs
• Urine protein/creatinine ratio
• If the patient is a gay or bisexual man, multi-site STI testing – throat, urine, and rectal specimens.

Question 3

What to do next for PrEP

Answer 3

If pt has been at risk of contracting HIV in the last 72 hrs, seek infectious diseases advice or sexual health advice about considering PEP.

Confirm the patient is HIV negative.

If baseline HIV test is negative but the patient has been at risk within 4 weeks of testing, they may need to be re-tested earlier than 3 months.

Offer vaccinations:

• HAV and HBV if not immune.
• HPV if eligible.

Discuss behavioural risk reducing strategies.

If not comfortable prescribing PrEP yourself, consider:

• requesting non-acute sexual health assessment or referring the pt to a suitable general practitioner via the PrEP map or
• advise pt to self-refer through the Auckland Sexual Health Regional Services

Question 4

Management if pt is eligible for funded PrEP

Answer 4

Printed copies of PrEP Information for Pts can be ordered from contact@nzaf.org.nz.

Advise that they will need to be reviewed every 3 m to reassess eligibility for funded PrEP, for Special Authority renewal and for testing.

Arrange to review in 1 week, once lab results are back, and prescribe tenofovir disoproxil + emtricibitane.

Complete the Special Authority form from the patient management system.

Arrange follow-up every 3 months.

Question 5

Management if the patient is not eligible for funded PrEP

Answer 5

Consider prescribing PrEP on a case by case basis if pt either:

• is at risk.
• may obtain psychological benefits from PrEP use (e.g. they struggle to find partners due to fear of HIV exposure).

Be aware that not all risk is always disclosed to prescribing clinicians.

Discuss prescription options.

If uncertain about prescribing non-funded PrEP, seek sexual health advice.

Question 6

Withdrawing PrEP

Answer 6

If pt has chronic hepatitis, seek ID advice or discuss with hepatologist before withdrawing PrEP, due to the risk of HBV reactivation.

If pt wishes to stop Ry, recommend continue taking PrEP for 48 hours after the last potential exposure.