When should I start PrEP?

Assess ongoing risk for HIV exposure and prescribe daily oral PrEP within 8 weeks after the last CAB injection or other prevention methods if HIV exposure is anticipated, including nonoccupational PEP.

cdc.gov - Learn About PrEP | Preventing New HIV Infections | Clinicians - CDC

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If a patient has a negative antigen/antibody test and an undetectable HIV-1 RNA test (if applicable) confirming they do not have HIV, PrEP can be prescribed. However, if a patient has both a positive antigen/antibody test and a detectable HIV-1 RNA test confirming that they have HIV, link that patient to HIV care and treatment. If results are discordant or ambiguous, a new blood specimen should be obtained for retesting, and PrEP should not be prescribed until true HIV status is confirmed. For assistance with ambiguous HIV test results, contact the PrEPline (1-855-448-7737) to get advice and find a laboratory that can do specialized testing.

The required HIV testing can be done by one of two methods:

Drawing blood, sending it to a laboratory for testing, and getting the results before prescribing or continuing PrEP. Administering a rapid, point-of-care, FDA-approved fingerstick HIV antigen/antibody blood test and drawing blood to send for laboratory testing. PrEP can be prescribed or continued based on a negative rapid antigen/antibody test result while awaiting laboratory test results. Oral rapid tests should not be used to screen for HIV infection when considering offering or continuing PrEP because they are less sensitive than blood tests and may not detect recent HIV infection.[19] A listing of FDA-approved HIV tests, specimen requirements, and time to detection of HIV infection is available at our laboratory testing page. Since PrEP is indicated for people at risk of getting HIV, health care providers should suspect acute HIV infection in patients who were recently exposed. Providers should ask all PrEP candidates with a negative or indeterminate result on an HIV test about whether they have experienced any signs or symptoms of viral infection in the preceding month or on the day of evaluation. For a patient with signs/symptoms of acute HIV infection within the prior 4 weeks, the following options are suggested: Test the patient with a combination antigen/antibody assay. Ideally, use a laboratory-based method. If a point-of-care antigen/antibody test is used and is non-reactive (negative), PrEP can be started while waiting for confirmatory laboratory test results. Test the patient’s HIV-1 RNA. If the patient has a measurable viral load that is <200 copies/mL, they may have HIV or a false-positive test result. PrEP should be deferred while testing is repeated on a new blood specimen. If the viral load is below the level of detection of the assay for the second blood specimen, and the patient has no signs/symptoms on that day, the first HIV-1 RNA test result was a false positive. The patient is considered to not have HIV, and PrEP can be started.

STI Testing

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Tests to screen for chlamydia, gonorrhea, and syphilis are recommended for all sexually active adults before starting oral or injectable PrEP.

Kidney Function

Oral PrEP. For patients taking F/TDF or F/TAF as PrEP, assess kidney function before starting PrEP. When used as PrEP, tenofovir can cause decreases in kidney function that are generally small, usually remain within the normal range, and are of no known clinical significance.[20,21] These small decreases typically return to earlier levels when the patient stops taking the medication.[10,11] Occasional cases of acute kidney failure, including Fanconi’s syndrome, have occurred.[22-29] Therefore, all patients considered for oral PrEP must have their kidney function assessed at PrEP initiation and periodically thereafter so that oral PrEP can be stopped, if necessary. Kidney function should be assessed by using the Cockcroft-Gault formula with the patient’s serum creatinine value to calculate an eCrCl. F/TDF is approved for use in people with eCrCl > 60 mL/min. F/TAF is approved for use in people with eCrCl <60 mL/min but ≥30 mL/min. Either F/TDF or F/TAF can be used when eCrCl > 60 mL/min. [27]

Injectable PrEP. For patients taking CAB, kidney assessments are not needed.

Hepatitis B (HBV) Serology

Emtricitabine and tenofovir can be used to treat active HBV infection. However, in people with active HBV, stopping these medicines can result in a rebound of HBV replication leading to liver damage. HBV infection is not a contraindication to PrEP, but all people considered for PrEP with F/TDF or F/TAF must be screened for HBV. Patients with active HBV infection should be educated about the risks of stopping oral PrEP without appropriate follow up so that if they stop using oral PrEP, their liver function can be closely monitored for reactivation of HBV replication that could cause liver damage.

Lipid Profile

For patients taking F/TAF as PrEP, assess cholesterol and triglyceride levels before starting PrEP.

cdc.gov - Learn About PrEP | Preventing New HIV Infections | Clinicians - CDC

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