HIV Pre-Exposure Prophylaxis Algorithm: Men Who Have Sex With Men

HIV PrEP: Men Who Have Sex with Men HIV Pre-exposure Prophylaxis Algorithm: Men Who Have Sex With Men

HIV Pre-exposure Prophylaxis Algorithm:
Men Who Have Sex With Men

Recent findings from clinical trials have shown that daily oral antiretroviral preexposure prophylaxis (PrEP) with a fixed-dose combination of tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) in men who have sex with men (MSM), men and women in heterosexual HIV-discordant couples, and heterosexual men and women demonstrated substantial reduction in the rate of HIV acquisition. The iPrEx study showed that prophylaxis with TDF/FTC provided an average of 44% reduction in the risk of HIV acquisition among MSM and transgender women who have sex with men. The CDC has published a clinical practice guideline for PrEP use for the prevention of HIV infection in MSM, heterosexual women and men, and IV drug users.


Before initiating PrEP: Confirm patient’s serologic test is HIV negative and there are no symptoms of acute HIV infection		No	▶	PrEP not indicated; seek HIV care
			▶	PrEP not indicated; seek HIV care
	Yes
▼
Confirm patient is at substantial, ongoing, high risk for acquiring HIV infection		No	▶	PrEP not indicated; seek HIV care
			▶	PrEP not indicated; seek HIV care
	Yes
▼
Confirm patient’s calculated CrCl ≥60mL/min (via Cockcroft-Gault formula)		No	▶	Seek physician counseling
			▶	Seek physician counseling
	Yes
▼
Other recommended actions: • Screen for hepatitis B virus (HBV) infection — Vaccinate if susceptible — Treat if active infection exists, regardless of PrEP initiation • Screen for hepatitis C virus (HCV) infection — Treat if active infection exists — Seek HCV care provider if needed • Screen and treat as needed for STI’s (syphilis, gonorrhea, chlamydia)


▼
Initiate PrEP Regimen: • Prescribe TDF/FTC 1 tablet daily for 90 days — In general, prescribe no more than a 90-day supply, renewable only after patient is confirmed HIV-uninfected • If active HBV infection is diagnosed, consider using TDF/FTC for both active HBV infection treatment and HIV prevention • Provide risk-reduction and PrEP medication adherence counseling and condoms • Every 3 months, perform an HIV antibody test; document negative result


▼				▼
Patient remains HIV negative after 3 months				Patient tests HIV positive

▼				▼
Follow-up: Evaluate and support PrEP medication adherence at each follow-up visit, more often if inconsistent adherence is identified • At least every 3 months: — Perform HIV testing and assess for symptoms of acute infection to document HIV-negative status — Assess risk behaviors and provide risk-reduction counseling and condoms — Perform STI testing in high risk patients (eg, previous STI, multiple sex partners) • At least every 6 months: — Assess renal function. Withhold PrEP if CrCl <60ml/min; consult with nephrologist if CrCl steadily declining (but remains ≥60 ml/min) — Perform STI testing • At least every 12 months: — Evaluate for continued need for PrEP				• Discontinue PrEP if HIV infection is acquired • Perform confirmatory HIV test. Measure CD4 count, viral load, genotypic HIV viral resistance • Convert to HIV treatment regimen without waiting for additional test results • Refer to experienced HIV care provider

NOTES

Key: STI = sexually transmitted infection

REFERENCES

Centers for Disease Control and Prevention: US Public Health Service. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2017 Update: A Clinical Practice Guideline. https://www.cdc.gov/hiv/pdf/guidelines/cdc-hiv-prep-guidelines-2017.pdf. Published March 2018. Accessed April 19, 2008.

(Rev. 4/2018)

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