Erie Family Health Centers (Dr. Foley); Hudson Headwaters Health Network (Dr. Farrell); Lancaster General Hospital Physicians Comprehensive Care, Penn Medicine, Lancaster General Health (Dr. Carr Reese) andrewvafoley@gmail.com
The authors reported no potential conflict of interest relevant to this article.
A fraction of those eligible for PrEP to prevent HIV infection receive a prescription. Newer drug regimens and updated recommendations can help you reduce that gap.
› Perform routine screening of patients for preexposure prophylaxis (PrEP) eligibility. B
› Prescribe oral or intramuscular PrEP for eligible patients after screening for HIV, other sexually transmitted infections, and hepatitis B, and establishing baseline renal function. A
Strength of recommendation (SOR) A Good-quality patient-oriented evidence B Inconsistent or limited-quality patient-oriented evidence C Consensus, usual practice, opinion, disease-oriented evidence, case series
References
More than 1.2 million Americans are living with HIV, and more than 30,000 new cases are diagnosed each year. While total incidence has declined since 2016, HIV remains a nationwide epidemic.1
Medications that prevent HIV acquisition, termed preexposure prophylaxis (PrEP), are an important tool to initiate in the primary care setting to reduce HIV transmission. However, while there are an estimated 1.2 million people eligible for PrEP, only 36% have received PrEP prescriptions.2 Several barriers that have impeded its widespread adoption include a lack of clinician knowledge and clinical resources for testing, high medication costs, and stigma around sexual health and intravenous (IV) drug use.
The value of PrEP
PrEP is chemoprophylaxis against the acquisition of HIV infection through the administration of an oral or injectable medication to people at risk for HIV. This practice began in the early 2000s, with the first oral regimen approved in 2012, and since has become an important tool in preventing HIV transmission.
When taken as prescribed, PrEP medications reduce the risk for acquiring HIV through sex by approximately 99% and can reduce the risk for acquiring HIV from injection drug use by approximately 74%.3 The US Preventive Services Task Force issued a Grade “A” recommendation to offer PrEP to people at high risk for HIV acquisition in June 2019 and reaffirmed it in a 2023 update.4
PrEP is notably distinct from postexposure prophylaxis (PEP), which is the administration of medication to prevent HIV infection after a possible exposure.
The available regimens
Regimens for PrEP include oral tablets or intramuscular (IM) injections.5 There are 3 PrEP regimens approved by the US Food and Drug Administration (FDA): tenofovir disoproxil fumarate/emtricitabine (Truvada), tenofovir alafenamide/emtricitabine (Descovy), and cabotegravir (Apretude).
Incomplete adherence to or abrupt discontinuation of oral PrEP could precipitate a hepatitis B flare.
Truvadais once-daily oral PrEP that was approved in 2012 and is now available in a generic formulation. Notable adverse effects of Truvada include a small negative impact on renal function and small reductions in bone mineral density; these have been noted in individual trials, but in meta-analyses such differences were not found to be statistically significant.6-8 The most common adverse effects of Truvada, experienced by up to 6% of patients, are gastrointestinal symptoms, fatigue, headache/dizziness, depression, and insomnia; most symptoms resolve within weeks.
