Management Plan for a Patient Continuing PrEP for HIV
Regular monitoring and follow-up are essential for patients continuing PrEP for HIV prevention, including quarterly HIV testing, STI screening, and periodic assessment of renal function to ensure safety and effectiveness. 1
Initial Assessment for PrEP Continuation
- Confirm HIV-negative status with a combined HIV antibody and antigen test before continuing PrEP 1
- Review adherence patterns and address any barriers to consistent PrEP use 1
- Assess ongoing risk factors and continued need for PrEP 1
- Review any medication changes that might interact with PrEP 1
Required Laboratory Monitoring
Quarterly Monitoring
- Combined HIV antibody and antigen test (mandatory every 3 months) 1
- Genital and non-genital gonorrhea and chlamydia testing by nucleic acid amplification test (NAAT) 1
- Syphilis testing 1
- Pregnancy testing for individuals of childbearing potential 1
First Quarterly Visit After Initiation
- Estimated creatinine clearance rate (in addition to quarterly tests above) 1
Annual Monitoring
- Estimated creatinine clearance rate (if normal at baseline and no risk factors) 1
- Hepatitis C virus antibody test 1
More Frequent Monitoring for Higher-Risk Patients
- Creatinine clearance every 3-6 months for patients:
- Hepatitis C testing every 3-6 months for people who inject drugs and MSM who use recreational drugs during sex 1
Prescription Guidelines
- PrEP prescriptions should not exceed 90 days without interval HIV testing 1
- For stable patients with good adherence, telemedicine visits may substitute for in-person visits, provided laboratory testing can be completed 1
Adherence Support
- Assess adherence at each visit and address any barriers 1
- Consider technology-based support such as alarms, pill boxes, electronic reminders, or automated text messaging services for patients with adherence challenges 1
- Discuss the importance of adherence for PrEP effectiveness, as greater adherence (≥70%) is associated with greater efficacy 3
Managing Interruptions in PrEP
- If PrEP has been discontinued for 7 or more consecutive days, perform a combined HIV antibody and antigen test before restarting 1
- For substantial non-adherence with high-risk exposure, consider discontinuing PrEP and initiating a 28-day course of 3-drug post-exposure prophylaxis (PEP) 1
- After completing PEP, seamlessly transition back to PrEP 1
Special Considerations
Injectable Cabotegravir PrEP (if applicable)
- Administer 600 mg intramuscularly every 8 weeks after an initial 4-week interval between the first two injections 1
- Perform rapid point-of-care HIV testing on the day of each injection 1
- If an injection is missed, resume as soon as possible after HIV testing 1
- If an injection is 8 or more weeks late, the first two injections should again be separated by 4 weeks before returning to the 8-week interval 1
Managing Breakthrough HIV Infection
- If HIV infection is suspected or confirmed while on PrEP, immediately transition to a dolutegravir-, bictegravir-, or ritonavir-boosted darunavir-based regimen pending resistance testing results 1, 4
- Obtain genotypic resistance testing to guide subsequent therapy 4, 5
Discontinuation Considerations
- Discuss the patient's ongoing risk profile if they consider discontinuing PrEP 1
- If discontinuing, PrEP should be continued for:
- Remind patients about the importance of condom use and the availability of PEP if PrEP is discontinued 1
Common Pitfalls to Avoid
- Failing to test for HIV before continuing PrEP, which could lead to undiagnosed infection and potential resistance 4, 5
- Inadequate STI screening, which may miss asymptomatic infections 1
- Overlooking renal function monitoring, especially in high-risk patients 2
- Not addressing adherence issues, which significantly impact PrEP effectiveness 3
- Missing the opportunity to transition from PEP to PrEP in patients with ongoing risk 1