HIV Pre-Exposure Prophylaxis (PrEP) Recommendations

Primary PrEP Recommendations

The American College of Physicians recommends TDF 300mg/FTC 200mg as a single daily oral pill for all populations at risk for HIV acquisition 1, 2
For men who have sex with men (MSM), a double dose (2 pills) of TDF/FTC is recommended on the first day of PrEP initiation to achieve protective drug levels more quickly 2
PrEP should be initiated as soon as feasible for individuals who have chosen to use it 2
The Centers for Disease Control and Prevention recommends daily tenofovir alafenamide/emtricitabine (TAF/FTC) for MSM with or at risk for kidney dysfunction, osteopenia, or osteoporosis 2
Event-driven PrEP using the "2-1-1" method is an effective alternative to daily dosing for MSM and transgender women 1, 3
Injectable cabotegravir every 8 weeks is recommended as PrEP for cisgender men and transgender women who have sex with men 2

The World Health Organization recommends PrEP for individuals at high risk of HIV acquisition, including men who have sex with men (MSM) with any of the following: condomless anal sex in past 6 months, multiple partners, or high risk score on validated assessment tools 3, 4, 5
PrEP is recommended for transgender women, especially those engaging in high-risk sexual behaviors 3, 4
Heterosexual serodiscordant couples (where one partner has HIV and the other does not) are also recommended for PrEP 5
People who inject drugs and share injection equipment should be considered for PrEP 5
At-risk heterosexual men and women with high-risk sexual behaviors may benefit from PrEP 5

The American College of Physicians recommends combined HIV antibody and antigen testing (with HIV RNA testing if acute infection is suspected) before starting PrEP 2, 6
Serum creatinine level should be assessed to evaluate kidney function 2
Hepatitis B surface antigen testing is essential before initiating PrEP 2
Hepatitis C antibody testing should be performed before starting PrEP 2
Hepatitis A antibody testing is recommended for MSM and people who inject drugs 2
Genital and non-genital testing for sexually transmitted infections should be conducted before initiating PrEP 2

At 1 month after initiation, combined HIV antibody and antigen test should be performed 6
Every 3 months, HIV testing should be conducted to ensure the patient remains HIV-negative 2, 7
Screening for sexually transmitted infections should be performed every 3 months 7
Every 6 months, creatinine assessment should be conducted to monitor kidney function 7
More frequent monitoring may be needed for patients with risk factors for kidney disease 7

Rule out acute HIV infection before initiating PrEP, especially if there are symptoms consistent with acute HIV infection 2
Kidney function should be regularly monitored, particularly in those with existing kidney issues 8
Bone density may be affected by TDF, and TAF/FTC may be preferred for those with osteopenia or osteoporosis 8
Caution is needed when using PrEP in patients with chronic hepatitis B due to risk of hepatitis flares if PrEP is discontinued 8

Daily dosing (not event-driven) is recommended for women as pharmacokinetic data suggests less consistent drug levels in vaginal tissues with intermittent dosing 8
PrEP is still recommended for at-risk transgender people, despite limited data on interactions between PrEP and hormone therapy 8
Daily oral TDF/FTC has shown effectiveness in people who inject drugs 8