PrEP for Minors at High Risk of HIV Infection
For adolescents under 18 years at high risk of HIV acquisition, prescribe daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) 300mg/200mg as the standard PrEP regimen, following the same protocols used for adults and adolescents. 1, 2
Recommended Regimen
- Daily oral TDF/FTC 300mg/200mg is the first-line PrEP regimen for adolescents, identical to the adult formulation 1, 2
- The CDC and WHO classify adolescents in the same category as adults for PrEP prescribing, with TDF + 3TC (or FTC) as the preferred backbone regimen 3
- For adolescent men who have sex with men (MSM), consider a double dose (2 pills) on the first day of initiation to achieve protective drug levels more quickly 2
- Daily dosing is critical—event-driven PrEP should not be used in adolescent females due to lower drug concentrations in vaginal tissue compared to rectal tissue 4, 2
Identifying High-Risk Adolescents Who Need PrEP
Offer PrEP to adolescents with any of the following risk factors:
- Adolescent MSM with condomless anal intercourse in the past 6 months, multiple male partners, HIV-positive partner(s), recent STI diagnosis, or methamphetamine/stimulant use 1, 2
- Heterosexual adolescents with an HIV-positive sexual partner, inconsistent condom use with partners of unknown HIV status, or recent bacterial STI diagnosis 1
- Transgender adolescents engaging in condomless anal intercourse or with multiple partners 1, 2
- Adolescents who inject drugs and share injection equipment 2
Pre-Initiation Testing Requirements
Before prescribing PrEP to any minor, perform the following mandatory tests:
- Combined HIV antibody and antigen testing (with HIV RNA if acute infection suspected) 1, 4, 2
- Serum creatinine level to calculate creatinine clearance 1, 4
- Hepatitis B surface antigen 1, 4, 2
- Hepatitis C antibody 1, 4
- Genital and non-genital STI screening (gonorrhea and chlamydia by NAAT) 1, 4
- Pregnancy testing for adolescents of childbearing potential 1, 4
Monitoring Schedule During PrEP Use
At 1 month after initiation:
Every 3 months:
- HIV antibody/antigen testing 1, 4, 2
- STI screening (gonorrhea, chlamydia, syphilis) 1, 4
- Pregnancy testing for those of childbearing potential 1, 4
- PrEP prescriptions should not exceed 90 days without interval HIV testing 4
Every 6 months:
- Creatinine assessment to monitor renal function 1, 2
- More frequent monitoring if baseline creatinine clearance <90 mL/min or risk factors for kidney disease present 1, 2
Critical Pitfalls to Avoid
- Never prescribe PrEP without ruling out acute HIV infection first—if symptoms consistent with acute HIV are present (fever, rash, lymphadenopathy), perform HIV RNA testing in addition to antibody/antigen testing 2, 5
- Do not use event-driven or "2-1-1" dosing in adolescent females—daily dosing is essential as tenofovir concentrates at 10-fold lower levels in vaginal tissue than rectal tissue 4
- Monitor adherence closely—PrEP efficacy exceeds 90% with detectable drug levels but drops to 44% with suboptimal adherence 1, 5, 6
- Counsel that PrEP does not prevent other STIs—condoms remain important for comprehensive protection 4
Special Considerations for Adolescents
- Pregnancy: Continue TDF/FTC during pregnancy if the adolescent becomes pregnant—it is safe with no documented adverse fetal effects 1
- Hepatitis B: If the adolescent is HBsAg-positive, consider indefinite continuation or transition to hepatitis B treatment if PrEP is stopped, and monitor for hepatitis flares 1
- Renal function: TAF/FTC may be preferred over TDF/FTC for adolescents with creatinine clearance <60 mL/min or osteopenia/osteoporosis 1
Efficacy and Real-World Effectiveness
- Daily TDF/FTC demonstrates >90% efficacy when adherence is maintained 1, 5, 6
- Efficacy is highly adherence-dependent—studies show 44% risk reduction in the iPrEx trial overall, but 92% reduction with detectable drug levels 1, 5, 6
- Enhanced adherence counseling is recommended for all adolescents initiating PrEP 3