What is the recommended approach for patient counseling and education about Pre-Exposure Prophylaxis (PrEP)?

Patient Counseling and Education About PrEP

PrEP counseling must emphasize that adherence to daily medication is the single most critical factor determining efficacy, and patients must understand that PrEP does not prevent other sexually transmitted infections and must be combined with comprehensive prevention services including risk-reduction counseling and condom access. 1

Core Educational Messages

Efficacy and Adherence

• Clearly explain that PrEP effectiveness is directly correlated with adherence - studies demonstrate that risk reduction is greatest in patients with detectable drug concentrations, meaning missed doses substantially increase HIV acquisition risk 2, 3
• Inform patients that PrEP is not 100% effective against HIV infection, even with perfect adherence 1
• For MSM, on-demand PrEP (2 tablets 2-24 hours before sex, then 1 tablet daily until 48 hours after last intercourse) represents a valid alternative to daily dosing with equivalent efficacy 1, 4

HIV Testing Requirements

• Confirm HIV-negative status immediately before starting PrEP using HIV antibody testing 1
• Test for acute HIV infection if the patient has flu-like symptoms (fever, headache, fatigue, arthralgia, myalgia, pharyngitis, rash, night sweats, adenopathy) or reports unprotected sex with an HIV-positive person in the preceding month 1
• Explain that patients must return for HIV testing every 2-3 months while on PrEP, as undetected HIV infection can lead to drug resistance 1
• Educate patients that PrEP alone does not constitute complete HIV treatment, and resistance mutations may emerge if taken with undetected infection 2, 3

Comprehensive Prevention Strategy

• Emphasize that PrEP must be part of a complete prevention package - it does not prevent other sexually transmitted infections like syphilis, chlamydia, or gonorrhea 1, 2
• Counsel patients to use condoms consistently and correctly to reduce contact with semen, vaginal secretions, or blood 2, 3
• Provide ready access to condoms at each visit 1
• Discuss the importance of knowing their HIV status and their partner(s)' HIV status 2, 3
• Explain that virologic suppression in HIV-positive partners reduces transmission risk 2, 3

Specific Counseling for Special Populations

Women of Reproductive Age

• Determine pregnancy plans, current pregnancy status, and breastfeeding status at every visit 1
• Disclose that safety data for infants exposed during pregnancy is incomplete, though no harm has been reported to date 1
• Do not prescribe PrEP to women who are breastfeeding 1
• Conduct pregnancy testing at each follow-up visit; if pregnant, discuss continued PrEP use with the patient and prenatal care provider 1

Patients with HIV-Positive Partners

• Determine whether the HIV-positive partner is receiving antiretroviral therapy 1
• Assist with linkage to care if the partner is not in care or not receiving treatment 1
• Target PrEP especially to uninfected persons in serodiscordant relationships 1

Monitoring and Follow-Up Education

Regular Testing Schedule

• HIV testing every 2-3 months (or more frequently for adolescents) 1, 2, 3
• STI screening every 6 months even if asymptomatic, with treatment as needed 1
• Creatinine clearance testing at 3 months after initiation, then every 6 months 1
• For women, pregnancy testing at each visit 1

Side Effects and Safety

• Inform patients about potential renal impairment and advise avoiding concurrent nephrotoxic agents (high-dose or multiple NSAIDs) 2, 3
• Educate about potential 1-1.5% bone mineral density loss with TDF-based PrEP, which returns to baseline upon discontinuation 5
• Screen for hepatitis B infection; if active infection exists, explain that TDF/FTC can serve dual purposes for both hepatitis B treatment and HIV prevention 1

Behavioral Counseling

Risk Assessment and Reduction

• Assess sexual risk behaviors at each quarterly visit 1
• Provide risk-reduction counseling at every follow-up, addressing specific behaviors that increase HIV exposure 1
• Evaluate substance use (methamphetamine, GHB/GBL) as part of comprehensive risk assessment 1
• Support patients to assess their sexual risk behavior and provide resources to help reduce risk 2, 3

Adherence Support

• Evaluate and support medication adherence at each follow-up visit, more frequently if inconsistent adherence is identified 1
• Explain that individuals who miss doses are at substantially greater risk of acquiring HIV than those who maintain adherence 2, 3
• Discuss taking PrEP around the same time every day for daily regimens 1

Common Pitfalls to Avoid

• Never initiate PrEP without confirming HIV-negative status - this can lead to suboptimal treatment and drug resistance if the patient has undetected infection 1
• Do not delay PrEP initiation for acute HIV testing if symptoms are absent and recent high-risk exposure did not occur 1
• Avoid prescribing more than a 90-day supply; renewal should only occur after confirming continued HIV-negative status 1
• Do not prescribe TDF-based PrEP to patients with creatinine clearance <60 mL/min 1
• Never counsel patients that PrEP eliminates the need for other prevention measures 1, 2

Discontinuation Counseling

• Perform HIV testing to confirm whether infection has occurred 1
• If HIV-positive, order resistance testing and establish linkage to HIV care 1
• If HIV-negative with ongoing risk, establish linkage to risk reduction support services 1
• For patients with active hepatitis B, arrange appropriate medication for continued hepatitis B treatment 1