HIV Pre-Exposure Prophylaxis Recommendations

Standard Dosing Regimens

The American Medical Association recommends Tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) 300mg/200mg taken once daily as the PrEP regimen for all populations at risk of HIV acquisition 1, 2
For Men Who Have Sex with Men (MSM), initiate with a double dose (2 tablets) on day 1, then continue once daily thereafter to achieve maximal protection within 24 hours 1, 2
Maximum protection is achieved within 24 hours of the double-dose initiation for MSM 1
When stopping PrEP, continue for 2 days after the last at-risk exposure for MSM 1, 2
Alternative on-demand "2-1-1" dosing is acceptable for MSM only: 2 tablets taken 2-24 hours before sex, 1 tablet 24 hours later, and 1 tablet 48 hours after the first dose 1, 2
For all other populations, take once daily without loading dose 1, 2, 4
Maximum protection requires approximately 7 days of daily dosing for all other populations 1, 2
When stopping PrEP, continue for 7 days after the last at-risk exposure for all other populations 1, 2
Daily dosing is critical for women because tenofovir concentrates at 10-fold lower levels in vaginal tissue compared to rectal tissue, with faster clearance 4

Pregnant and breastfeeding individuals can safely use daily TDF/FTC with no documented adverse fetal effects 1, 2, 3
For MSM with creatinine clearance 30-60 mL/min or osteopenia/osteoporosis, consider tenofovir alafenamide/emtricitabine (TAF/FTC) instead of TDF/FTC 1, 3

Before prescribing PrEP, obtain combined HIV antibody and antigen testing, serum creatinine and estimated creatinine clearance, hepatitis B surface antigen, hepatitis C antibody, nucleic acid amplification testing for gonorrhea and chlamydia, syphilis testing, and pregnancy test for individuals of childbearing potential 4

Every 3 months, perform combined HIV antibody/antigen testing, STI screening, pregnancy testing for individuals of childbearing potential, and estimated creatinine clearance 4
Additional monitoring includes HIV testing at 1 month after initiation and more frequent renal monitoring if baseline creatinine clearance <90 mL/min or if patient has diabetes or hypertension 4

PrEP should be discussed with all sexually active adults and adolescents and individuals who inject drugs 1, 2
High-risk populations include MSM with condomless anal intercourse, multiple partners, or HIV-positive partner(s), transgender individuals engaging in condomless sex or with multiple partners, and heterosexual individuals with HIV-positive sexual partners or inconsistent condom use with partners of unknown status 1, 2, 3

PrEP efficacy exceeds 90% when adherence is maintained with detectable drug levels 3
Efficacy is highly adherence-dependent, dropping to 44% with suboptimal adherence versus 92% with detectable drug levels 3

PrEP does not prevent other sexually transmitted infections—condoms remain recommended for STI prevention 1, 4
For hepatitis B surface antigen-positive individuals, consider indefinite continuation or transition to hepatitis B treatment if stopping PrEP, as discontinuation can cause hepatitis flares 3
Enhanced adherence counseling is essential, particularly for adolescents and women, given the adherence-dependent efficacy 3