Administration of pre-exposure prophylaxis against HIV infection
- Kenneth H Mayer, MD
Kenneth H Mayer, MD
- Infectious Disease Attending and Director of HIV Prevention Research
- Beth Israel Deaconess Medical Center
- Professor of Medicine
- Harvard Medical School
- Medical Research Director
- The Fenway Institute
- Douglas Krakower, MD
Douglas Krakower, MD
- Division of Infectious Diseases
- Beth Israel Deaconess Medical Center
- Assistant Professor of Medicine, Harvard Medical School
- Research Scientist, The Fenway Institute
- Section Editors
- John G Bartlett, MD
John G Bartlett, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — HIV; Pulmonary Infections
- Professor Emeritus
- Johns Hopkins University School of Medicine
- Paul E Sax, MD
Paul E Sax, MD
- Section Editor — HIV
- Clinical Director, Division of Infectious Diseases
- Brigham and Women's Hospital
- Professor of Medicine
- Harvard Medical School
Up to two million new HIV infections occur yearly worldwide. As there is no effective vaccine to prevent HIV transmission, behavioral and biomedical HIV prevention strategies are needed to reduce HIV acquisition [1-3]. For HIV-uninfected patients, pre-exposure prophylaxis (PrEP) using antiretroviral medications is an evidence-based way to prevent new infections among those at greatest risk.
This topic will review how to administer PrEP to appropriate candidates. A discussion of how to assess patients for PrEP and other strategies to prevent HIV infection (eg, the use of antiretroviral therapy for HIV-infected patients, post-exposure prophylaxis for HIV-uninfected patients, and male circumcision) are discussed elsewhere. (See "Patient evaluation and selection for HIV pre-exposure prophylaxis" and "HIV infection: Risk factors and prevention strategies" and "Management of nonoccupational exposures to HIV and hepatitis B and C in adults" and "Management of healthcare personnel exposed to HIV".)
ASSESSING PATIENTS FOR PrEP
To determine who should receive pre-exposure prophylaxis (PrEP), clinicians should assess the potential benefits and risks of therapy (table 1). Among those who are adherent, PrEP using tenofovir disoproxil fumarate-emtricitabine (TDF-FTC) can reduce the risk of HIV transmission by greater than 90 percent, although rare infections may still occur [4-6].
The initial evaluation of a patient who is interested in initiating PrEP is summarized below and described in detail elsewhere:
●Clinicians should obtain a detailed sexual and drug use history to determine if the patient is at high risk of HIV acquisition, and therefore likely to benefit from PrEP. (See "Patient evaluation and selection for HIV pre-exposure prophylaxis", section on 'Assessing risk of HIV acquisition'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- ASSESSING PATIENTS FOR PrEP
- ANTIVIRAL THERAPY
- Preferred regimen
- Patient counseling
- - Medication adherence
- - Condom use
- - Drug use behaviors
- - Symptoms of acute HIV
- Risk of drug resistance
- - Acquired drug resistance
- - Transmitted drug resistance
- Alternatives to daily oral therapy
- Alternative delivery systems
- PATIENT MONITORING
- Routine monitoring and counseling
- - Frequency
- - What to monitor
- - Counseling
- Patients who develop renal abnormalities
- Women who become pregnant
- Patients with sexually transmitted infections
- Patients with or at risk for osteoporosis
- Patients with newly diagnosed HIV infection
- DURATION OF PRE-EXPOSURE PROPHYLAXIS
- COST CONSIDERATIONS
- EFFICACY OF ORAL PRE-EXPOSURE PROPHYLAXIS
- Men who have sex with men
- Transgender women
- Heterosexual men
- Heterosexual women
- Injection drug users
- Effect on HSV-2 transmission
- SUMMARY AND RECOMMENDATIONS