HIV Pre-Exposure Prophylaxis Recommendations

Current PrEP Recommendations

The American College of Physicians recommends TDF/emtricitabine (TDF/FTC) as the PrEP agent for all populations at risk of HIV through sexual exposure or injection drug use 1, 2
Daily oral TAF/FTC use should be limited to cisgender men and others whose exposures do not include receptive vaginal sex or injection drug use alone, as recommended by the International Antiviral Society-USA panel guidelines 1
On-demand (2-1-1) dosing has only been validated with TDF/FTC, not with TAF/FTC, according to the JAMA guidelines 1, 2

On-demand TDF/FTC (2-1-1 dosing) is effective for HIV prevention among men who have sex with men (MSM) with an 86% risk reduction in the IPERGAY study, as reported by the JAMA guidelines 2, 3
The 2-1-1 dosing schedule consists of 2 doses of TDF/FTC taken 2-24 hours before sex, 1 dose 24 hours after the first dose, and 1 dose 24 hours after the second dose, as recommended by the Journal of Microbiology, Immunology and Infection 2, 3, 4

For women, daily TDF/FTC is especially important as tenofovir concentrates at lower levels in vaginal tissue than in rectal tissue and clearance is faster, according to the JAMA guidelines 2, 5
On-demand PrEP is only recommended for cisgender men and transgender women having planned receptive anal sex, as recommended by the International Antiviral Society-USA panel guidelines 1
For people who inject drugs, daily TDF/FTC is the only recommended regimen, according to the JAMA guidelines 1, 2

TDF-based PrEP is not recommended for persons with creatinine clearance below 60 mL/min/1.73 m², as recommended by the JAMA guidelines 2, 6
For individuals with active HBV infection, on-demand PrEP with either TDF or TAF is not recommended due to risk of hepatitis flare and hepatic decompensation, according to the JAMA guidelines 6

HIV testing with a combination antigen-antibody assay is mandatory before initiating any PrEP regimen, as recommended by the JAMA guidelines 6
Follow-up visits every 3 months are recommended for HIV testing and STI screening, according to the JAMA guidelines 6
PrEP prescriptions should not exceed 90 days without interval testing for HIV infection, as recommended by the JAMA guidelines 6

The International Antiviral Society-USA guidelines recommend that for vaginal exposures, daily dosing of TDF/FTC should be initiated with a double dose followed by single daily tablets, with dosing to continue until at least 7 days after last sexual activity 7, 8

For receptive vaginal sex, 7 days of daily dosing is required for full protection, according to the International Antiviral Society-USA guidelines 7, 8
For receptive anal sex, protection can be achieved more rapidly, within 2-3 days with adequate dosing, as supported by the International Antiviral Society-USA guidelines 7, 9

The International Antiviral Society-USA guidelines specify starting with a double dose of TDF/FTC on day 1, followed by single daily tablets thereafter, to achieve protective drug levels more rapidly 7, 8

On-demand PrEP is only validated for cisgender men and others having planned receptive anal sex, not for receptive vaginal exposures, as stated by the International Antiviral Society-USA guidelines 7, 9
Daily TAF/FTC should be limited to cisgender men and others whose exposures do not include receptive vaginal sex, as it lacks validation for vaginal HIV prevention, according to the International Antiviral Society-USA guidelines 7
A combination HIV antigen-antibody assay should be performed within 7 days before starting PrEP to exclude HIV infection, as recommended by the International Antiviral Society-USA guidelines 9

When stopping PrEP, daily dosing must continue for at least 7 days after last sexual activity to maintain protection during the washout period, as advised by the International Antiviral Society-USA guidelines 7, 10