Pre-Exposure Prophylaxis (PREP)

Pre-exposure prophylaxis (PrEP) is the use of ARVs by people who are not infected with HIV before HIV exposure in order to prevent the acquisition of HIV. With optimum adherence, oral PrEP is more than 90% effective in reducing the risk of HIV infection.

Eligibility criteria for oral PrEP

Oral PrEP should be offered to individuals who are HIV negative and are at substantial risk of HIV infection. Individuals at high risk have:

Multiple sexual partners
Inconsistent and incorrect use of condoms
Engage in transactional sex
Use or abuse of injectable drugs and alcohol
Episode(s) of STI within the last six months
Discordant couples, especially if the HIV positive partner is not on ART or has been on ART for less than six months or those with high viral load
Recurrent users of PEP

In addition, individuals should commit and be supported to adhere to PrEP. Sub-populations considered to be at high risk for HIV infection include: people in sero-discordant relationships, sex workers, and long distance truck drivers, men who have sex with other men (MSM), adolescent girls and young women and pregnant and breastfeeding women.

Recommended regimens for oral PrEP

Medicine	Adult dose	Frequency	Duration
tenofovir (TDF) 300mg + emtricitabine (FTC) 200mg	1 tablet FDC	once only	period of substantial risk
or tenofovir (TDF) 300mg + lamivudine (3TC) 300mg	1 tablet FDC	once only	period of substantial risk

NB: In cases where TDF/FTC or TDF/3TC are both not available, TDF single formulation can be used

NB It takes about 7 days of daily dosing PrEP to be effective. During this period, other HIV preventive options such as abstinence and condoms must be used.

PrEP medications should be continued for 28 days after the last potential HIV exposure in those wanting to stop taking PrEP.
PrEP may be used intermittently during periods of perceived HIV acquisition risk, rather than continually and lifelong, as is the case with antiretroviral treatment
Other regimens and formulations for PrEP will be introduced in the future

Contraindications for PrEP

HIV positive status
Unknown HIV status
Recent exposure (in the past 72 hours)
Evidence or suspicion of HIV primary infection (characterised by a flu-like illness)
Allergy to any of the PrEP medicines
Unwilling/unable to adhere to PrEP
Known renal impairment
Estimated creatinine clearance of <60 cc/min

Follow up and Monitoring of PrEP clients

After initiating PrEP, the client should be reviewed after one month to monitor adherence and side effects as well as resupply of medicines, subsequent clinic visits should be every three months
Perform an HIV antibody test every three months and document negative HIV status
For women, perform a pregnancy test based on clinical history. Pregnancy is not a contraindication for PrEP use
Review the client's understanding of PrEP, any barriers to adherence, tolerance to the medication as well as any side effects
Review the client's risk exposure profile and perform risk reduction counselling
Evaluate and support PrEP adherence at each clinic visit
Evaluate the client for any symptoms of STls at every visit and treat as needed
Provide risk assessment and risk reduction counselling at every visit

Discontinuing PrEP

PrEP can be discontinued in the following circumstances:

On seroconversion (HIV positive)
Intolerable toxicities and side effects associated with PrEP use
Changed life situations resulting in lowered risk of HIV acquisition
Social adverse events associated with PrEP
Poor adherence despite efforts to improve daily pill taking
When a personal choice is made to stop PrEP. Such individuals should be linked to other preferred HIV prevention options
In sero-discordant couples when HIV infected partner on ART has achieved viral suppression (VL<1,000 copies/ml) with at least 6 months of ART

NB It is important to ensure that the client continues to take the medicines for at least 28 days after the last exposure.