What counseling and management should a 39-year-old woman dating an HIV-positive partner receive regarding HIV testing, condom use, pre‑exposure prophylaxis (PrEP), STI screening, pregnancy planning, and needle safety?

Counseling for a 39-Year-Old Woman Dating an HIV-Positive Partner

This woman should be offered daily oral pre-exposure prophylaxis (PrEP) with FTC/TDF as part of a comprehensive HIV prevention strategy that includes baseline and regular HIV testing, condom counseling, STI screening, and pregnancy planning discussions. 1

Immediate HIV Testing

• Perform baseline HIV testing using a fourth-generation antigen/antibody assay before initiating any prevention strategy, as this test can detect infection 11-18 days post-exposure and identifies both acute and established infection. 2
• If she reports a recent high-risk exposure (within 72 hours), offer post-exposure prophylaxis (PEP) immediately with FTC/TDF plus raltegravir, as PEP effectiveness decreases significantly after 72 hours. 1
• Retest for HIV at least annually if she remains at ongoing risk, or more frequently (monthly to quarterly) if she initiates PrEP. 1

Pre-Exposure Prophylaxis (PrEP) Counseling

Daily FTC/TDF should be offered as PrEP because having an HIV-positive sexual partner places her at high risk for HIV acquisition, particularly if the partner's viral load is not consistently suppressed on antiretroviral therapy. 1

Key PrEP Considerations:

• Assess the partner's HIV treatment status: If the HIV-positive partner is on effective ART with sustained viral suppression (undetectable viral load), transmission risk is dramatically reduced, but PrEP may still be appropriate depending on adherence certainty and her comfort level. 1
• Screen for renal function and hepatitis B before starting PrEP, as FTC/TDF requires baseline assessment of kidney function and HBV status. 1
• Emphasize that PrEP is part of an integrated strategy, not a replacement for condoms, as it does not protect against other STIs or pregnancy. 1
• Reassess risk regularly and consider discontinuing PrEP if circumstances change (e.g., relationship ends, partner achieves sustained viral suppression). 1

Condom Use and Risk Reduction

• Recommend consistent condom use for all sexual encounters to reduce HIV transmission risk and protect against other sexually transmitted infections. 1
• Provide specific risk reduction counseling covering recent sexual practices and substance use that may increase HIV risk. 1
• Explain that condoms combined with an undetectable viral load in the partner (U=U) and/or PrEP provides layered protection against HIV transmission. 1

STI Screening

Perform routine periodic screening for common STIs based on sexual history and anatomic sites of exposure, as recent diagnosis of STIs (especially syphilis, gonorrhea, or chlamydia) indicates high HIV risk and supports PrEP initiation. 1

• Screen for syphilis, gonorrhea, and chlamydia at baseline and regularly (at least annually, more frequently if on PrEP). 1
• Recent STI diagnosis is itself an indication for PrEP, as it reflects high-risk sexual behavior. 1

Pregnancy Planning

• Discuss pregnancy intentions explicitly, as this affects both PrEP continuation and HIV prevention strategies. 1
• If she desires pregnancy:
  • Ensure the HIV-positive partner is on effective ART with undetectable viral load before attempting conception, as this virtually eliminates transmission risk. 1
  • Continue PrEP during conception attempts and pregnancy if the partner's viral suppression is uncertain or if additional protection is desired. 1
  • Provide emergency contraception if she receives PEP to prevent unintended pregnancy during the prophylaxis period. 1
• If pregnancy occurs, universal opt-out HIV screening should be performed early in pregnancy and repeated in the third trimester if she remains at high risk. 1

Partner HIV Status and Viral Load Assessment

• Encourage the HIV-positive partner to engage in care and achieve viral suppression, as an undetectable viral load eliminates sexual transmission risk (U=U). 1
• Verify the partner's HIV status and treatment adherence through direct discussion, as partners with unknown or unsuppressed viral loads pose higher transmission risk. 1
• If the partner's HIV status is truly unknown (not just undisclosed), encourage partner testing and counseling. 1

Needle Safety (If Applicable)

• Assess for any injection drug use in either partner, as sharing needles dramatically increases HIV transmission risk. 1
• If injection drug use is present, offer harm reduction services including needle exchange programs and consider PrEP even more strongly. 1
• Screen for hepatitis C if injection drug use is reported, as HCV co-infection affects HIV management. 1

Follow-Up Testing Schedule

If Starting PrEP:

• HIV testing before PrEP initiation (fourth-generation antigen/antibody test). 1, 2
• Retest monthly to quarterly depending on individual risk while on PrEP. 1
• Screen for STIs every 3-6 months while on PrEP. 1

If Not on PrEP but Remains at Risk:

• Annual HIV testing at minimum, more frequently if high-risk behaviors continue. 1, 3
• Immediate testing if acute HIV symptoms develop (fever, rash, myalgia, fatigue, lymphadenopathy). 4

Common Pitfalls to Avoid

• Don't delay PrEP while waiting for partner's viral load information—offer it based on her risk profile and adjust later if circumstances change. 1
• Don't assume she knows her partner's true HIV status or viral load—many people in serodiscordant relationships lack accurate information about their partner's treatment status. 1
• Don't use oral fluid rapid tests for screening in this high-risk context—they are less sensitive for acute infection than blood-based fourth-generation tests. 2
• Don't forget to assess for intimate partner violence—HIV disclosure and prevention discussions can trigger relationship conflict or abuse. 1, 5
• Don't provide prevention counseling as a barrier to testing—HIV testing should be routine and not contingent on lengthy counseling sessions. 1