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:
Assess renal function.
Every 6 months:
Test for bacterial STIs, including rectal and pharyngeal sites if indicated.