Should a 70-year-old HIV-negative gay male with normal renal function have his daily oral pre-exposure prophylaxis (emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg) prescription renewed?

Yes, Renew His PrEP Prescription

You should renew this 70-year-old gay male's daily oral emtricitabine/tenofovir disoproxil fumarate (TDF/FTC) prescription, as age alone is not a contraindication to PrEP, and he meets the criteria with negative HIV status and normal renal function. 1, 2

Key Considerations for This Patient

Age and PrEP Eligibility

• PrEP is recommended for all sexually active adults at risk for HIV acquisition, regardless of age 1, 2
• The 2020 IAS-USA guidelines explicitly state that PrEP should be discussed with "all sexually active adults and adolescents" without upper age restrictions 1
• The 2024 IAS-USA guidelines reinforce that PrEP should be offered to "all sexually active persons" requesting it, without limiting access based on age criteria 2

Renal Monitoring Requirements - Critical for Older Adults

While his current renal function is normal, older adults (>50 years) are at higher risk for TDF-associated renal dysfunction 3:

• Monitor creatinine clearance more frequently than standard protocols:

  • At 1 month after renewal 1
  • Then every 3-6 months (not just annually) given his age 1
  • Standard protocol calls for quarterly monitoring at first visit, then annually, but patients over 50 or at risk for kidney injury should have monitoring every 3-6 months 1

• TDF is contraindicated if creatinine clearance drops below 60 mL/min 3, 4

• Renal dysfunction with TDF is usually reversible upon discontinuation 3

• Research shows a mean eGFR decrease of approximately 14 mL/min can occur, typically appearing by week 4 and stabilizing thereafter 5, 6, 7

Alternative Regimen Option

Consider switching to tenofovir alafenamide/emtricitabine (TAF/FTC) if he develops any renal concerns or has risk factors for bone disease 1:

• TAF/FTC is specifically recommended for MSM with creatinine clearance between 30-60 mL/min or those with osteopenia/osteoporosis risk 1
• TAF has superior renal and bone safety biomarkers compared to TDF 8
• However, TAF efficacy is not superior to TDF for HIV prevention 1

Required Monitoring at Renewal

Quarterly Testing (Every 3 Months):

• Combined HIV antibody and antigen test 1
• Estimated creatinine clearance (given his age >50) 1
• STI screening: gonorrhea and chlamydia by NAAT (genital and nongenital sites) 1
• Syphilis testing 1

Annual Testing:

• Hepatitis C antibody (more frequently if he uses recreational drugs during sex) 1

Prescription Limits:

• Do not prescribe more than 90 days without interval HIV testing 9, 3

Common Pitfalls to Avoid

1. Don't assume age disqualifies PrEP eligibility - Guidelines explicitly support PrEP for older adults
2. Don't use standard annual renal monitoring - His age mandates more frequent monitoring (every 3-6 months)
3. Don't miss the opportunity to discuss TAF/FTC - While TDF/FTC remains first-line, TAF may be preferable if renal or bone concerns emerge
4. Don't forget comprehensive STI screening - High rates of STIs persist in PrEP users regardless of age 8, 10

Dosing Considerations for MSM

For this gay male patient, he can use either daily dosing or event-driven (2-1-1) dosing 1, 3, 1, 2:

• Daily dosing: One tablet daily, with double dose (2 tablets) on first day for rapid protection within 24 hours 1
• Event-driven (2-1-1) dosing: 2 tablets 2-24 hours before sex, then 1 tablet at 24 hours and another at 48 hours after the first dose 1, 3, 1
• Event-driven dosing is only validated for MSM with receptive anal sex, not for other exposure routes 1, 2

The choice between daily and event-driven dosing should be based on his sexual activity patterns and preference 2.