What prophylactic HIV medications, such as Truvada (emtricitabine and tenofovir disoproxil fumarate), and laboratory tests are recommended for a 37-year-old male with a history of anabolic steroid-induced metabolic derangements, ongoing testosterone replacement therapy, elevated hematocrit, and low absolute neutrophil count, who is at risk for sexually transmitted diseases (STDs)?

HIV Pre-Exposure Prophylaxis and Laboratory Monitoring Recommendations

This patient does not require HIV prophylaxis because he has no detectable HIV infection and should instead receive pre-exposure prophylaxis (PrEP) with daily tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) 300mg/200mg given his ongoing sexual risk factors. 1, 2

PrEP Indication and Regimen Selection

This patient meets clear criteria for PrEP based on his sexual risk profile and concern about STD exposure:

• Daily oral TDF/FTC is the recommended first-line PrEP regimen for all populations at risk of HIV through sexual exposure, with proven efficacy exceeding 90% when adherence is maintained 1, 2, 3
• The patient qualifies for PrEP based on multiple risk factors including sexual activity with partners of unknown HIV status and concern about STD exposure 1, 3
• On-demand (2-1-1) dosing is an alternative option only if the patient is a cisgender man or transgender woman having planned receptive anal sex, providing 86% risk reduction in this specific population 1, 2, 4

Critical Contraindication: Hepatitis B Status

Before prescribing PrEP, hepatitis B surface antigen (HBsAg) testing is mandatory because:

• TDF/FTC has activity against hepatitis B virus, and abrupt discontinuation in HBsAg-positive individuals can cause acute hepatitis flares or hepatic decompensation, particularly in those with cirrhosis 1, 5
• On-demand PrEP is specifically contraindicated in patients with active HBV infection due to this flare risk 1, 5
• Given this patient's history of Anavar-induced hepatic injury, HBV status is particularly important to establish 1

Pre-Initiation Laboratory Testing Required

Before prescribing PrEP, the following tests must be performed 1, 3:

• HIV testing with combination antigen-antibody assay (must be performed within 7 days of PrEP initiation) 1
• HIV RNA testing if acute HIV infection is suspected based on symptoms or recent high-risk exposure 1, 3
• Hepatitis B surface antigen (HBsAg) - mandatory before initiation 1, 3
• Hepatitis C antibody testing 3, 5
• Serum creatinine and estimated creatinine clearance - TDF-based PrEP is contraindicated if creatinine clearance is below 60 mL/min 1, 5
• STI screening: nucleic acid amplification testing for gonorrhea and chlamydia (oral, rectal, urine, and genital sites as appropriate), plus syphilis serology 1, 3

Ongoing Monitoring Schedule During PrEP Use

Follow-up visits must occur every 3 months with the following assessments 1, 3:

• HIV testing with combination antigen-antibody assay at every visit (quarterly) - PrEP prescriptions should not exceed 90 days without interval HIV testing 1, 5
• STI screening every 3 months: gonorrhea, chlamydia, and syphilis testing 1, 3, 5
• Renal function assessment every 6 months (creatinine and estimated creatinine clearance), with more frequent monitoring for patients over age 50, those with baseline creatinine clearance <90 mL/min, or those with diabetes or hypertension 1, 3
• Hepatitis C serologic testing at least annually, with more frequent testing in high-risk individuals 3, 5
• Adherence counseling at every visit - efficacy is highly adherence-dependent, with 92% risk reduction when drug levels are detectable versus only 44% with suboptimal adherence 3, 6

Special Considerations for This Patient

Testosterone Therapy and Elevated Hematocrit

• The elevated hematocrit from testosterone replacement therapy does not contraindicate PrEP use 1
• Continue monitoring hematocrit as part of testosterone therapy management, separate from PrEP monitoring 1

Low Absolute Neutrophil Count

• Grade 3-4 neutropenia (<750/mm³) occurs in 3-7% of patients on TDF/FTC-based regimens 7
• The patient's current "low" absolute neutrophil count should be quantified - if >750/mm³, this is not a contraindication to PrEP 7
• If neutrophils are <750/mm³, consider investigating other causes before attributing to future PrEP use, as baseline neutropenia may be unrelated 7
• Monitor complete blood count at baseline and periodically during PrEP use 7

History of Anavar-Induced Hepatotoxicity

• Hepatitis B testing is particularly critical given the hepatic injury history - if HBsAg-positive, indefinite continuation or transition to hepatitis B treatment may be needed if PrEP is ever stopped 3, 5
• Monitor ALT/AST at baseline and periodically, though routine hepatic monitoring is not specifically required for PrEP in HBsAg-negative individuals 1

Common Pitfalls to Avoid

• Never initiate PrEP without confirming HIV-negative status within 7 days - initiating PrEP during undiagnosed acute HIV infection is the most common cause of resistance development 1
• Do not prescribe on-demand PrEP for receptive vaginal exposures - this dosing strategy is only validated for cisgender men and transgender women having receptive anal sex 1, 2
• Do not overlook hepatitis B testing - this is mandatory before PrEP initiation to prevent hepatitis flares upon discontinuation 1, 3
• Do not extend prescription intervals beyond 90 days - quarterly HIV testing is essential to detect breakthrough infections early 1, 5

Vaccination Recommendations

• Hepatitis A and B vaccination if not immune (check serologies at baseline) 1
• HPV vaccination if age-appropriate (recommended for men through age 26, may be given through age 45) 1