Key next steps in providing PrEP are:
Discuss PrEP with your patient.
- Ask what he or she is currently doing to protect themselves from HIV.
- Discuss the benefits and risks of PrEP.
Identify insurance or other reimbursement for your patient.
- Many private insurers cover PrEP but may require prior authorization.
- Several programs have been established to help cover the cost of PrEP and associated care, including Gilead Sciences' patient assistance and co-pay coupon programs.
Educate patients about the medications and their safe use.
- Discuss potential drug side-effects (which are most common in the first month of taking PrEP) and how they can be managed.
- Describe the symptoms of possible acute HIV infection; explain that the patient should contact the clinic without delay if these occur.
Prescribe daily TDF/FTC (Truvada).
- This is the only medication approved by the FDA for use as PrEP in all populations.
- Any licensed prescriber can prescribe TDF-FTC as PrEP. Specialization in infectious diseases or HIV medicine is not required.
- Refill periods should be limited to the recommended intervals for repeat HIV testing (at least every three months).
Provide support for medication adherence.
- One pill a day, every day, is the goal.
- Emphasise that sticking to the medication schedule is critical to PrEP providing effective protection; describe the impact of non-adherence on PrEP efficacy.
- Assess patient's past issues with medication adherence; identify and address barriers to adherence.
- Support patient to fit daily dose with their daily routine; identify useful reminders (e.g. phone alarms) and devices (e.g. pill boxes).
- In follow-up visits, monitor adherence in a non-judgmental manner.
Provide support to reduce HIV risk behaviors.
- Repeated follow-up visits provide opportunities for brief, repeated risk-reduction counselling.
- Reinforce that for a PrEP user, condoms provide additional benefit against HIV as well as other STIs.
- Provide referrals to prevention services.
- For women who do not wish to become pregnant, provide effective contraception.
- For patients who inject drugs, provide referrals to drug treatment services and needle and syringe programs.
Provide clinical follow-up and monitoring.
- Follow-up visits at least every 3 months for:
- HIV testing,
- Adherence counselling,
- Behavioral risk reduction support,
- Side effect assessment,
- STI symptom assessment, and
- Pregnancy test for women.
- At 3 months and every 6 months thereafter:
- Every 6 months:
- Test for bacterial STIs, including rectal and pharyngeal sites if indicated.