Good to Know: Pre-Exposure Prophylaxis Guidelines

Are you at a high risk of getting HIV? Safer sex acts or behaviors are combined with the use of antiretroviral therapy to increase the protection and lower the chances of getting the virus. There are a lot of benefits of adhering to PrEP guidelines. It’s good to know these guidelines to remain safe and protected.

Prevention is better than a cure and it’s good to know effective measures to decrease the risk of getting HIV. At HIVPrEP, we provide you with detailed information and guideline resources on how best you can protect yourself from getting HIV.

While the infection rates have been substantially reduced among the general population (in some countries), HIV is still a serious issue, especially for young adults (aged 13-24). The chances of getting the above-mentioned infection depend on individual sexual behavior and the traits of the sexual partner, among other factors.

The FDA officially accepted the use of PrEP medications in 2012 to decrease an individual’s risk or chances of HIV exposure. These drugs are highly effective, providing over 90% protection if taken daily, adhering to dose information as prescribed by a doctor, and using other sexual HIV prevention practices (such as using condoms).

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🔍What Are HIV Pre-Exposure Prophylaxis Guidelines?

Knowing PrEP guidelines to protect yourself from viral infection is more beneficial than using post-exposure prophylaxis (PEP) drugs. Sometimes, PEP is less effective at preventing virus acquisition than avoiding exposure with PrEP drugs.

In this article, we discuss pre-exposure prophylaxis guidelines for the general public to help individuals who are at high risk of HIV exposure to diligently follow the right procedure (or guidelines) for optimal protection.

Most of the guidelines detail important procedures in the use of antiretroviral medication to effectively manage HIV, including prevention and treatment. If you wholeheartedly followed the prescribing information as instructed, an individual with a risk of HIV-1 infection is assured of higher protection despite the viral exposure.

The target population for HIV PrEP guidelines includes (but is not limited to):

• men-men sex (MSM) – engaging in unprotected anal sex;
• transgender individuals at high risk of HIV infection through sexual practices;
• a person who has a partner who is HIV-positive;
• heterosexual women having sexual intercourse with MSM or individuals who inject drugs;
• persons who risk unprotected sex using stimulant drugs like cocaine;
• individuals involved in transactional sex;
• serodiscordant couples;
• individuals prescribed PEP medication.

Individuals looking to prevent getting HIV after engaging in an unprotected single high-risk sexual act are recommended PEP medication – administered not more than 72 hours after the incident for the drug to be effective (the earlier you take PEP med, the better). PEP drugs are prescribed to be used for 28 days [1].

📌Important Points

The U.S. FDA approved the use of antiretroviral medicines – a combination of tenofovir (TDF) and emtricitabine (FTC) to be used for PrEP by individuals who are at high risk of HIV infection or exposure. This has opened gateways for quality medical measures to be used by those at a high-risk of being infected [2].

A significant level of TDF/FTC efficacy has been achieved where individual adherence to PrEP guidelines is high. This demonstrates how valuable this drug combination is and it is highly recommended in HIV-1 infection intervention and protection approaches.

Depending on the mode of acquiring the virus (i.e. penile, rectal or vaginal), adherence to the use of PrEP medication substantially increases the level of protection.

Some important points to consider include:

• prior to using TDF/FTC, an initial evaluation is needed. A doctor may discuss the option of PrEP with a patient – identifying high-risk potential and advising on how to safely protect themselves by using PrEP medications together with other safe sex practices for higher protection. This involves knowing the patient’s last high-risk exposure and if PEP is needed;
• an individual must be tested for HIV-1 before PrEP is offered and must be regularly tested every 12 weeks while PrEP is taken. Individual must have negative results from HIV tests;
• if PrEP is prescribed, the patient should know the drug efficacy (based on factual data), important information on drug compliance, side effects, helpful information on tenofovir/emtricitabine long-term use, and the importance of follow-up to ensure there is no new development of viral infection;
• a medical specialist should perform a full checkup for illnesses that need special treatment and advise whether TDF/FTC is safe with those diseases. The doctor should also screen a patient for acute HIV infection symptoms. Possible signs include flu-like symptoms such as body aches, fever and painful/aching throat among others;
• other required initial labs include checking for Hep C, especially in individuals who have injected drugs, serum creatinine, pregnancy, a surface antigen of HBV (HBsAg), measure the level of kidney function and determine the patient’s stage of kidney disease (E-GFR), among others;
• perform STI testing on individuals who want to start PrEP if not previously done. Check for gonorrhea and chlamydia and its appropriate sites, syphilis and HPV vaccine if required;
• to achieve full protection when using PrEP meds, 5-7 days of using PrEP are needed for anal intercourse and around 20 days for vaginal intercourse;
• prior to starting TDF/FTC, evaluate renal function with approximate creatinine clearance (CrCl). Only prescribe TDF/FTC for individuals with creatinine clearance ≥60 ml/min. While using this drug, a patient should visit a doctor at least every 12 weeks to monitor the level of CrCl.

Clinical follow-up and close monitoring are necessary for HIV-uninfected persons taking PrEP. An individual prescribed PrEP must comply with a one month and thereafter three-month follow-up to assess side effects, HIV infection risk behaviors and adherence.

While taking this medication, pregnancy testing and HIV screening testing should be done regularly every 12 weeks.

A doctor should also assess estimated CrCl after six months of using PrEP medication and test for STDs such as gonorrhea, chlamydia, syphilis, and other related diseases.

Testing for bone mineral density should be performed regularly. Bone health is mandatory for any person with a known history of pathologic fractures, or who has notable risk factors for osteoporosis.

In some instances, if acute HIV-1 infection exists while administering PrEP, TDF/FTC PrEP medication should be stopped and another combination of antiretroviral therapy with tenofovir/emtricitabine such as a protease inhibitor or TDF/FTC + dolutegravir should be prescribed as a treatment for HIV/AIDS [3].

PrEP medication should be discontinued if a person wishes to stay away from unsafe sex practices or when HIV exposure is no longer a risk. It should only be terminated if an individual is guaranteed safety from high risk of HIV infection/exposure.

It’s the responsibility of clinicians and medical specialists or doctors to educate persons being administered PrEP about the benefits of adhering to guidelines and actionable/possible ways/strategies to reduce HIV risk behaviors.

Those are some of the guidelines we have summarized. Depending on your nationality, you might get other detailed guidelines not listed here since medical procedures vary slightly for some countries.

📁Useful Resources & Guidelines

There are several country-specific policies, guidelines, and resources for providing detailed information on how to deliver PrEP effectively in a given population.

Documents listed below detail comprehensive guidelines on how to analyze, apply and manage PrEP and how to effectively use ART for people exposed to HIV infection. Although there might be a slight difference when handling PrEP using specific tools, the concept still remains unchanged.

These are some of the country-specific available resources and guidelines on how to effectively handle PrEP for various types of population:

• CDC Clinical Practice Guidelines (2017) – gives detailed information for daily administration of oral PrEP to lower the risk factors of acquiring HIV infection;
• Preexposure prophylaxis for the prevention of HIV infection in the United States – 2017 update (a clinical practice guideline). Particularly for the United States healthcare providers detailing what’s new in the PrEP arena;
• BHIVA/BASHH Guidelines on the Use of HIV Pre-Exposure Prophylaxis (2018) (United Kingdom) – providing evidence-based guidance on best clinical practice in administering, monitoring, and support of PrEP for prevention of HIV virus acquisition;
• Consolidated Guidelines for Prevention and Treatment of HIV in Uganda (2018) – detailed guidelines on the provision of PrEP and treatment of HIV/AIDS for all people exposed to HIV;
• Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. Comprehensive guidelines on the use of PrEP to effectively prevent the acquisition of HIV;
• Guidelines on Use of Antiretroviral Drugs for Treating and Preventing HIV Infection (2018). Comprehensive guidelines on ARVs for treating and preventing HIV (for the Republic of Kenya) – recommending PrEP for use in HIV uninfected individuals who are at substantial ongoing risk or high chances of acquiring HIV;
• PrEP Implementation Framework – (2017) from the National AIDS & STI Control Program (NASCOP). This framework provides guidance on the provision and monitoring of PrEP in Kenya;
• The American College Health Association (ACHA) Guidelines for HIV Pre-Exposure Prophylaxis. A detailed guide for HIV PrEP management in college/university health services.

There are several guidelines (not listed here) that are specifically tailored for specific countries. All these guidelines aim to educate, providing detailed medical information and support for PrEP for people at high risk of getting HIV-1.

To ensure you stay safe and protected, follow the given guidelines while adhering to your doctor’s prescription. It’s necessary to know that PrEP medications don’t guarantee you 100% safety. You must apply other safe sex practices to stay fully protected from getting HIV.

📚References:

1. HIV Prevention: Using HIV Medication to Reduce Risk. Post-Exposure Prophylaxis. Hiv.gov. Retrieved May 23, 2018.
2. CDC Statement on FDA Approval of Drug for HIV Prevention. Media Statement. Cdc.gov. Retrieved July 16, 2012.
3. Pre-exposure Prophylaxis for the Prevention of HIV Infection in the United States (2017 Update). US Public Health Service. A Clinical Practice Guideline. Retrieved 2017.