HIV Testing Prior to PrEP Initiation

Clinical Considerations

The American College of Physicians and other medical societies recommend that a rapid HIV test be performed before dispensing PrEP, as fever, fatigue, and new-onset rash are classic symptoms of acute HIV infection, and initiating PrEP in someone with undiagnosed HIV could lead to viral resistance and inadequate treatment 1, 2
PrEP must never be initiated or continued in HIV-positive individuals because monotherapy with cabotegravir or dual therapy with tenofovir/emtricitabine does not constitute a complete treatment regimen and will lead to resistance mutations, according to the International Antiviral Society-USA guidelines 1
The 2020 International Antiviral Society-USA guidelines explicitly state that a reactive rapid point-of-care HIV assay should be confirmed by combined antibody and antigen testing with subsequent HIV RNA confirmation 1, 3

The Centers for Disease Control and Prevention recommend starting with a rapid HIV test immediately at the pharmacy or referring for immediate testing, as results are available within 1 hour and can be performed by non-licensed staff 4
If the rapid test is reactive, do not dispense PrEP and refer immediately for confirmatory combined antibody/antigen testing plus HIV RNA testing, as recommended by the International Antiviral Society-USA 1, 3
If the rapid test is negative but symptoms persist, HIV RNA testing should still be obtained because acute HIV infection can occur during the "window period" when antibody tests may be negative but the patient is infected and highly infectious 1

The International Antiviral Society-USA recommends immediately transitioning to a complete antiretroviral treatment regimen, such as dolutegravir-based, bictegravir-based, or boosted darunavir-based regimens, pending resistance testing results 1, 3
Obtain genotypic resistance testing including integrase mutations before finalizing the treatment regimen, as recommended by the International Antiviral Society-USA 1, 6