How does a young bisexual male start Pre-Exposure Prophylaxis (PrEP)?

How to Start PrEP in a Young Bisexual Male

Initiate daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC, one 300/200 mg tablet daily) as soon as eligibility is confirmed, which can occur at the first visit if baseline testing is negative. 1, 2

Step 1: Determine Eligibility and Perform Baseline Testing

Before prescribing PrEP, you must confirm the patient is HIV-negative and assess ongoing risk:

HIV Testing Requirements

• Perform a combined HIV antibody/antigen test immediately before starting PrEP 1
• If the test was performed within 7 days of the visit and is negative, PrEP can be initiated same-day 1
• If no recent test is available, perform a rapid point-of-care test at the visit and start PrEP only if negative, but also send a laboratory-based antibody/antigen test 1
• If acute HIV infection is suspected (symptoms of acute retroviral syndrome or unprotected sex with HIV-positive partner in past month), perform HIV RNA testing and withhold PrEP until results return 1

Required Laboratory Testing

• Confirm creatinine clearance ≥60 mL/min using the Cockcroft-Gault formula 1
• Screen for hepatitis B infection (HBsAg); vaccinate if susceptible 1
• Screen for sexually transmitted infections (gonorrhea, chlamydia, syphilis) at baseline 1, 3

Risk Assessment

For a young bisexual male, confirm ongoing high risk for HIV acquisition, which includes:

• Condomless anal or vaginal sex with partners of unknown HIV status 1
• Multiple sexual partners 4
• Sex with partners known to have HIV who are not virally suppressed 1
• Recent bacterial STI diagnosis 3

Step 2: Prescribe the Medication Regimen

The standard regimen is TDF/FTC (Truvada) 300/200 mg, one tablet daily 1, 2, 3

Initial Prescription

• Prescribe no more than a 30-day supply initially, renewable only after confirming HIV-negative status 1
• After the first month, prescribe 90-day supplies with refills contingent on quarterly HIV testing 1, 3

Alternative Considerations

• On-demand (2-1-1) dosing with TDF/FTC is an option if the patient's risk is exclusively from planned receptive anal sex (not applicable for vaginal exposures) 1, 2, 3
• The 2-1-1 schedule: 2 tablets 2-24 hours before sex, 1 tablet 24 hours later, 1 tablet 24 hours after that, continuing daily until 48 hours after last sexual contact 1, 2
• TAF/FTC (tenofovir alafenamide/emtricitabine) daily may be considered only if the patient has creatinine clearance 30-60 mL/min or bone density concerns, but is NOT validated for receptive vaginal exposures 1, 2

Critical Counseling Points

• Emphasize that efficacy is highly dependent on adherence to daily dosing 1
• For receptive anal sex, protective drug levels are achieved within 2-3 days of daily dosing 2
• For any vaginal exposures, 7 days of daily dosing is required for full protection 2
• PrEP does not protect against other STIs; condoms should still be encouraged 1

Step 3: Provide Comprehensive Prevention Services

PrEP must be delivered as part of a comprehensive prevention package, not as a standalone intervention 1:

• Risk-reduction counseling at initiation and each follow-up 1
• PrEP medication adherence counseling 1
• Ready access to condoms 1
• Discussion of sexual behaviors and partners 5

Step 4: Schedule Follow-Up Monitoring

A follow-up visit is required 30 days after initiation, then quarterly thereafter 1:

At 30-Day Follow-Up

• Repeat HIV antibody/antigen testing 1
• Assess adherence and side effects 1
• Evaluate ongoing risk behaviors 1

At Quarterly Follow-Up Visits (Every 3 Months)

• HIV testing with combination antibody/antigen assay is mandatory before each prescription refill 1, 2, 3
• STI screening (gonorrhea, chlamydia, syphilis) every 3 months, including rectal and pharyngeal swabs for men who have sex with men 3, 5
• Creatinine clearance monitoring 1
• Hepatitis C serologic testing at least annually 3
• Adherence assessment and counseling 1
• Risk behavior assessment 1

Monitoring Intervals

• PrEP prescriptions should not exceed 90 days without interval HIV testing 2, 3
• Telemedicine visits may substitute for in-person visits if the patient is stable and laboratory testing can be completed remotely 1

Common Pitfalls to Avoid

• Do not prescribe PrEP without confirming HIV-negative status - TDF/FTC is contraindicated in persons with unknown or positive HIV status 1
• Do not use on-demand dosing for patients with vaginal exposures - this regimen is only validated for men who have sex with men having receptive anal sex 1, 2
• Do not prescribe TDF-based PrEP if creatinine clearance is <60 mL/min 2, 3
• Do not skip comprehensive STI screening - only 32% of gay and bisexual men receive comprehensive care including rectal and pharyngeal swabs, yet these are essential 5
• Do not assume adherence without assessment - younger men and those with higher education levels are more likely to receive comprehensive care, but adherence support is needed for all 5, 6

Special Considerations for Young Bisexual Men

• Age, race/ethnicity, and income are not associated with willingness to take PrEP, suggesting equal acceptability across subpopulations 7
• Young men who have sex with men often prefer flexible PrEP options that accommodate demanding schedules 8
• Men already engaging in condomless anal sex are more willing to take PrEP (those at highest risk), and there is limited evidence of risk compensation 7
• Providing PrEP to men who test infrequently may engage them in routine HIV/STI testing and create ongoing sexual health dialogue 7

If Recent High-Risk Exposure Occurred

If the patient reports unprotected sex with potential HIV exposure within the past 72 hours, initiate 3-drug post-exposure prophylaxis (PEP) for 28 days first, then transition seamlessly to 2-drug PrEP 1