What are the key considerations when discussing Pre-Exposure Prophylaxis (PrEP) with a patient?

Key Considerations for Discussing PrEP with Patients

When discussing PrEP with patients, begin by emphasizing that adherence to daily medication is the single most critical factor determining efficacy—this must be the cornerstone of your conversation, as PrEP effectiveness is highly dependent on consistent use. 1, 2

Initial Risk Assessment and Eligibility Discussion

Conduct a specific risk assessment covering the past several months to determine sexual and substance use practices that warrant PrEP consideration. 2 Focus your assessment on:

• Recent STI diagnoses (especially syphilis, gonorrhea, or chlamydia within the past 6 months), which indicate high HIV risk 2
• Partners with known HIV infection, particularly if their viral load status is unknown or unsuppressed 2
• Injection drug use behaviors, including sharing equipment or daily injection of cocaine/methamphetamines 2
• Use of post-exposure prophylaxis (PEP) more than twice in the past year, which signals ongoing high-risk exposure 2
• Sex work or transactional sex involvement 2

Core Educational Messages to Deliver

Explicitly state that PrEP is not 100% effective against HIV infection, even with perfect adherence, and does not prevent other sexually transmitted infections. 1, 2 This sets realistic expectations from the outset.

Frame PrEP as part of a comprehensive prevention package, not a standalone intervention—it must be combined with risk-reduction counseling and condom access. 1, 2 Provide ready access to condoms at each visit. 1, 2

Explain the monitoring requirements clearly: patients must return every 2-3 months for HIV testing, as undetected HIV infection while taking PrEP can lead to drug resistance. 1, 2 This is non-negotiable for safe PrEP use.

HIV Testing Requirements Before Initiation

Confirm HIV-negative status immediately before starting PrEP using an HIV antibody test, ideally a fourth-generation antigen-antibody assay. 1, 2 Never initiate PrEP without this confirmation. 1

Test for acute HIV infection if the patient reports flu-like symptoms (fever, headache, muscle soreness, sore throat, rash, swollen lymph nodes) or unprotected sex with an HIV-positive person in the preceding month. 1, 2

Special Population Considerations

Women of Reproductive Age

At every visit, determine pregnancy plans, current pregnancy status, and breastfeeding status. 1, 2 This is a mandatory component of each encounter.

Disclose that safety data for infants exposed during pregnancy is incomplete, though no harm has been reported to date. 1, 2 Allow the patient to make an informed decision with this information.

Do not prescribe PrEP to women who are breastfeeding—this is an absolute contraindication. 1, 2

Men Who Have Sex with Men

For MSM, discuss on-demand PrEP as a valid alternative to daily dosing with equivalent efficacy, which may improve adherence for those with infrequent sexual activity. 1, 2

Renal and Bone Health Screening

Confirm that calculated creatinine clearance is ≥60 mL/min using the Cockcroft-Gault formula before prescribing TDF-based PrEP. 2 Do not prescribe TDF-based PrEP below this threshold. 1

For patients with pre-existing osteopenia or osteoporosis, TDF-based PrEP is not recommended. 3 Consider TAF/FTC instead for MSM with bone health concerns. 3

Hepatitis B Considerations

Screen for hepatitis B infection at baseline—vaccinate if susceptible, or treat if active infection exists, regardless of the PrEP decision. 2 If active hepatitis B is diagnosed, TDF/FTC can serve dual purposes as both HIV prevention and hepatitis B treatment. 2

Prescribing and Follow-Up Framework

Prescribe no more than a 90-day supply, renewable only after HIV testing confirms continued HIV-negative status. 1, 2 This built-in checkpoint ensures regular monitoring.

Schedule follow-up visits every 2-3 months for HIV testing, adherence evaluation, risk behavior assessment, and STI symptom screening. 1, 2

Conduct comprehensive STI screening every 6 months, even if asymptomatic, and treat as needed. 1, 2 This addresses the high STI incidence among PrEP users. 4

Check serum creatinine at 3 months after initiation, then every 6 months while on PrEP. 1, 2

Adherence Counseling Strategy

At each visit, evaluate and support medication adherence, with more frequent assessment if inconsistent adherence is identified. 2 The efficacy of PrEP is strongly associated with adherence. 5

Regularly reassess the patient's risk profile—PrEP may become unnecessary if sexual or injection drug use behaviors change, and discontinuation should be considered. 2

Positive Framing to Enhance Uptake

Consider incorporating positive sexual health messaging into your discussion, as research shows PrEP increases emotional intimacy, reduces sexual anxiety, and removes barriers to physical closeness—these motivations can improve uptake and adherence. 6 This destigmatizes sexual pleasure while promoting prevention.

Common Pitfalls to Avoid

Never delay PrEP initiation for acute HIV testing if symptoms are absent and recent high-risk exposure did not occur. 1

Do not prescribe PrEP to patients with unknown or positive HIV status—this is contraindicated and can lead to resistance. 2

Avoid prescribing TDF-based PrEP to patients with creatinine clearance <60 mL/min. 1

Discontinuation Counseling

When discontinuing PrEP, perform HIV testing to confirm whether infection has occurred. 1, 2 If HIV-positive, order resistance testing and establish immediate linkage to HIV care. 1, 2 If HIV-negative with ongoing risk, establish linkage to risk reduction support services. 1, 2

For patients with active hepatitis B diagnosed at PrEP initiation, consider appropriate medication for continued hepatitis B treatment upon PrEP discontinuation. 2