What assessment questions should be asked of a patient presenting for HIV pre‑exposure prophylaxis (PrEP) evaluation?

Assessment Questions for HIV Pre-Exposure Prophylaxis (PrEP) Visit

Adopt a serostatus-neutral approach and offer PrEP to all sexually active individuals requesting it, without requiring specific risk criteria or screening tools 1. However, a structured assessment ensures appropriate initiation and safety monitoring.

Essential Assessment Domains

Sexual History and HIV Exposure Risk

Ask directly about:

• Condomless anal or vaginal intercourse in the past 6 months (frequency and partner types) 2
• Number of sexual partners in the past 6 months 2
• HIV status of sexual partners, particularly if any partners are HIV-positive or of unknown status 1, 2
• Type of sexual activity: receptive vs. insertive anal intercourse (receptive carries higher risk) 2
• Transactional sex or sex work involvement 2
• Condom use patterns and barriers to consistent use 1

For men who have sex with men (MSM), the Taiwan guideline provides a validated risk index that can structure your assessment 2:

• Age (18-28 years = highest risk score)
• Number of male partners in past 6 months (>10 = highest risk)
• HIV-positive partners (more than one = highest risk)
• Episodes of receptive condomless anal sex
• Episodes of insertive condomless anal sex
• Methamphetamine use

A score ≥10 indicates high risk, though current guidelines recommend offering PrEP regardless of scoring 1, 2.

Substance Use Assessment

• Methamphetamine, cocaine, or other stimulant use during sex 2
• Injection drug use and needle-sharing practices 1
• Alcohol use that may impair judgment around safer sex practices
• Any substance use disorder requiring concurrent treatment 1

Partner and Relationship Context

• Monogamous vs. non-monogamous relationships
• For partners of people with HIV: Is the partner on antiretroviral therapy? What is their viral load status? 1
  • Note: PrEP may be deferred for monogamous partners of virally suppressed individuals (<200 copies/mL), but should still be offered if requested due to possible undisclosed exposures 1

Recent HIV Exposure History

• Any substantial HIV exposure within the past 72 hours requiring post-exposure prophylaxis (PEP) instead 1
• Previous PEP use and whether transitioning from PEP to PrEP 1
• Most recent HIV test and date (if within 7 days and negative, can initiate immediately) 1

Medical History and Contraindications

• Renal function history: chronic kidney disease, diabetes, hypertension 3
• Hepatitis B status (important because stopping tenofovir can cause hepatitis B flare)
• Current medications that may interact or affect renal function
• Bone health concerns or osteoporosis risk factors
• Pregnancy status and intentions (PrEP is safe during pregnancy and lactation) 3
• Allergies to tenofovir or emtricitabine

Sexually Transmitted Infection (STI) History

• Current STI symptoms at any anatomic site (oral, genital, rectal) 1
• Recent STI diagnoses in past year
• Frequency of STI screening 1

Psychosocial and Structural Barriers

Address potential barriers to adherence 1:

• Housing stability
• Insurance and financial concerns
• Transportation access to clinic visits
• Mental health conditions requiring support
• Stigma concerns or disclosure fears
• Criminal legal involvement

Adherence Assessment

• Ability to take daily medication (for oral PrEP)
• Preference for daily oral vs. long-acting injectable options
• Previous experience with daily medications and adherence patterns
• Support systems for medication reminders

Key Clinical Pitfalls to Avoid

• Do not use risk screening tools as gatekeepers to deny PrEP access; guidelines explicitly recommend offering PrEP to anyone requesting it 1
• Do not delay PrEP initiation for extensive laboratory workup if recent HIV test is negative 1
• Do not assume monogamous relationships eliminate risk; undisclosed exposures occur 1
• Do not overlook transgender women, who face significant barriers and high HIV risk despite limited specific data 2
• Do not forget to assess for immediate PEP needs if exposure occurred within 72 hours 1

Documentation of Willingness and Understanding

• Patient's understanding of PrEP efficacy and need for adherence
• Commitment to quarterly follow-up visits 3
• Understanding of continued need for condoms and STI prevention 1
• Interest in doxycycline post-exposure prophylaxis (doxyPEP) for bacterial STI prevention if MSM or transgender woman 1

This structured assessment balances the guideline recommendation to offer PrEP broadly with the clinical need to ensure safe initiation and identify individuals who will benefit most from this highly effective prevention tool.