Preexposure prophylaxis for preventing HIV infection: Routine practice in primary care

Amy L. Wiser

doi:10.3949/ccjm.91a.23079

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Figure 1
Considerations for initiation of preexposure prophylaxis.
HIV = human immunodeficiency virus; MSM = men who have sex with men; MSW = men who have sex with women; PrEP = preexposure prophylaxis; TGW = transgender women; WSM = women who have sex with men
Based on information from references 2,6,14,22–25.

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TABLE 1

Suggested questions for obtaining a sexual history

Questions	Comments and follow-up questions
Are you sexually active?	Explore what sexual activity means for the patient
Who are your sexual partners?	Ask in an anatomic- and gender-inclusive manner: partner with a penis, partner with a vagina, only male, only female, transgender men, transgender women, gender nonconforming
Do you have a current partner or partners?	Does your partner have multiple partners?
How many partners have you had in the past 6 months?
How do you typically meet partners?	Specifically inquire regarding online, app, casual hookup, anonymous sexual encounters, sex workers, or friends
What sexual activities do you participate in?	Specifically inquire regarding oral, vaginal, anal, top (insertive), bottom (receptive)
Do you use condoms or barriers with steady or new partners?	Guide to quantify as never, rarely, 50%, or always
Do you or your partner(s) have a history of sexually transmitted infections?	Any infections in past 6 months?
Do you have plans for prevention of pregnancy?	Are you using or interested in contraception?
Do you have a history of commercial sex work?

Based on information from reference 21.

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TABLE 2

Testing in patients prescribed preexposure prophylaxis for HIV prevention

PrEP medications	Emtricitabine/tenofovir disoproxil fumarate	Emtricitabine/tenofovir alafenamide	Cabotegravir
Initial testing

Human immunodeficiency virus (HIV) antigen/antibody	X	X	X
HIV RNA	X	X	X
Creatinine/estimated creatinine clearance	X	X	X
Rapid plasma reagin syphilis screening	X	X	X
Gonorrhea/chlamydia nucleic acid amplification testing^a	X	X	X
Hepatitis A virus specific immunoglobulin G	X	X	X
Hepatitis B surface antigen	X	X	X
Hepatitis B surface antibody	X	X	X
Hepatitis B core antigen	X	X	X
Hepatitis C virus-specific immunoglobulin G	X	X	X
Pregnancy test^b	X		X
One month

HIV antigen/antibody	X	X	X
HIV RNA			X
Every 2 months

HIV antigen/antibody			X
Rapid plasma reagin syphilis screening^c	Not applicable	Not applicable	X
Gonorrhea/chlamydia nucleic acid amplification testing^a,^c,^d			X
Pregnancy test^b			X
Every 3 months

HIV antigen/antibody	X	X
Creatinine^e	X	X
Rapid plasma reagin syphilis screening	X	X	Not applicable
Gonorrhea/chlamydia nucleic acid amplification testing^a,^d	X	X
Pregnancy test^b	X
Annually

Creatinine^e	X	X	X
Hepatitis C virus-specific immunoglobulin G^f	X	X	X
Lipid panel		X

↵^a3-site testing of self-collected urine or vaginal specimen, pharyngeal swab, and rectal swab.
↵^bUrine pregnancy testing if childbearing potential.
↵^cTesting intervals may be extended to every 4 months.
↵^dGonorrhea testing semiannually and chlamydia testing at least yearly for cisgender women.
↵^eRenal function testing may be performed semiannually.
↵^fHepatitis C virus immunoglobulin G may be tested more regularly and as requested.
Based on information from references 2,6,14,22–25.

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TABLE 3

Preexposure prophylaxis prescribing, safety, and other considerations

PrEP medications
Generic name	Emtricitabine/tenofovir disoproxil fumarate	Emtricitabine/tenofovir alafenamide	Cabotegravir
Dosing	200/300 mg daily or on-demand	200/25 mg daily	600-mg gluteal intramuscular injection
Population	Cisgender women/cisgender men,^a transgender women, transgender men,^a persons who inject drugs	Cisgender men,^b transgender women^b	Cisgender women,^a cisgender men,^b transgender women^b
Prescribing	30-day initial prescription 90-day maintenance	30-day initial prescription 90-day maintenance	Optional lead-in 30-mg oral daily for 4 weeks Initial injection, then second injection in 4 weeks Maintenance injection every 8 weeks
Safety
Side effects	Headaches, abdominal pain, nausea, weight loss	Diarrhea, weight gain	Tenderness and redness at injection site
Renal function	Estimated creatinine clearance > 60 mL/minute	Estimated creatinine clearance > 30 mL/minute	No renal restrictions
Drug interactions	Drugs compromising renal function (antivirals, aminoglycosides, and high-dose nonsteroidal anti- inflammatory drugs) may increase concentration	St. John’s wort may decrease concentration Antibiotics rifabutin and rifapentine should not be coadministered May consider rifampin if benefit outweighs risk	Carbamazepine, oxcarbazepine, phenytoin, phenobarbital, rifampicin, and rifapentine may decrease concentration May consider rifabutin if benefit outweighs risk
Other concerns	Avoid use with osteopenia or osteoporosis or with renal impairment	Avoid use with osteopenia or osteoporosis	Caution if gluteal fillers or if at increased bleeding risk Caution with end-stage kidney disease not yet receiving dialysis
Other
Missed dose	Continue daily dosing	Continue daily dosing	> 7 days late: oral preexposure prophylaxis bridging until next injection > 8 weeks late: restart administration

↵^aIncludes insertive and receptive vaginal or anal sex.
↵^bInsertive vaginal or anal sex and receptive anal sex; not approved for risk from receptive vaginal sex.
Based on information from references 2,6,14,22–25,29.

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TABLE 4

Commonly used preexposure prophylaxis diagnosis codes

ICD-10 code	Description	Use
Z01.812	Encounter for preprocedural laboratory examination	Pretreatment testing
Z20.6	Contact with and (suspected) exposure to human immunodeficiency virus	PrEP initiation and monitoring
Z20.2	Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission	PrEP initiation and monitoring Sexually transmitted infections screening
Z11.4	Encounter for screening for human immunodeficiency virus	Human immunodeficiency virus screening
Z11.3	Encounter for screening for infections with a predominantly sexual mode of transmission	Sexually transmitted infections screening

ICD-10 = International Classification of Disease, Tenth Revision, Clinical Modification; PrEP = preexposure prophylaxis

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TABLE 5

Preexposure prophylaxis education and prescribing resources

Clinician prescribing resources

• PrEPline: National Clinician’s Consultation Center (https://nccc.ucsf.edu/clinical-resources/prep-resources/prep-quick-guide)

• Integrating HIV Care, Treatment & Prevention Services into Primary Care—A Toolkit for Health Centers (https://bphc.hrsa.gov/media/p4c-toolkit-2018.pdf)

• HIV Nexus Centers for Disease Control and Prevention Resources for Clinicians (www.cdc.gov/hiv/clinicians/index.html)

• The AIDS Education and Training Center (AETC) Program National Coordinating Resource Center (https://aidsetc.org)

• The National Network of STD Clinical Prevention Training Centers (http://nnptc.org)

Patient education resources

• US Preventive Services Task Force. Let’s Talk About It: Preventing HIV with PrEP (www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/hiv-prep-prevention-discussion-guide.pdf)

• US Department of Health and Human Services Office of the Assistant Secretary for Health (OASH). Ready, Set, PrEP (http://readysetprep.hiv.gov)

• Centers for Disease Control and Prevention. PrEP 101. PrEP Access. Is PrEP Right For Me? (www.cdc.gov/hiv/pdf/basics/prep/cdc-hiv-stsh-prep-brochure-english.pdf)