PrEP Guidelines for Men Who Have Sex with Men

PrEP Medication Selection

The American College of Physicians recommends daily oral emtricitabine/tenofovir disoproxil fumarate (Truvada) as first-line PrEP for MSM at risk of HIV, with quarterly HIV and STI screening at all potentially exposed anatomic sites (oral, rectal, and urogenital) 1
Daily oral TDF/emtricitabine is the recommended PrEP regimen for MSM with proven efficacy in preventing HIV acquisition 2, 3, 1
A 1-week lead-in period is recommended before adequate tissue levels are achieved for rectal and penile exposures 1
Continue for 1 week after the last sexual exposure when discontinuing 1
Descovy (emtricitabine 200 mg/tenofovir alafenamide 25 mg) is specifically indicated for MSM with renal impairment (creatinine clearance 30-60 mL/min), osteopenia, or osteoporosis 4
Critical limitation: Descovy is NOT recommended for cisgender women or event-driven "2-1-1" dosing 4

Before starting PrEP, obtain mandatory tests, including HIV testing with combination antigen-antibody assay (if acute HIV suspected, add HIV RNA testing) 1
Serum creatinine and estimated creatinine clearance (do not start TDF-based PrEP if <60 mL/min) 2, 1
Hepatitis B surface antigen (HBsAg) 1
Hepatitis C antibody 1

Every 3 months, perform HIV testing with combination antigen-antibody assay 2, 3, 1
Every 3 months, perform three-site STI screening (rectal, pharyngeal, urogenital) for gonorrhea and chlamydia by NAAT 1
Every 6-12 months, perform serum creatinine and estimated glomerular filtration rate 2, 1
More frequent renal monitoring (every 3-6 months) for patients >50 years, taking hypertension/diabetes medications, or with baseline eGFR <90 mL/min 1

Do not prescribe TDF-based PrEP if creatinine clearance <60 mL/min 2, 1
Do not prescribe TDF-based PrEP if osteopenia or osteoporosis (use Descovy instead for MSM) 2, 4
Use caution when discontinuing TDF/emtricitabine in patients with chronic hepatitis B—risk of acute flares or hepatic decompensation, particularly with cirrhosis 1

Immediately add a boosted protease inhibitor (darunavir/ritonavir or darunavir/cobicistat) and/or dolutegravir to TDF/emtricitabine while awaiting HIV RNA and resistance testing results 2, 3
Switch to a recommended initial antiretroviral regimen once HIV is confirmed 1