HIV Pre-Exposure Prophylaxis (PrEP) Clinical Practice Guidelines (2019)

British HIV Association (BHIVA)/British Association for Sexual Health and HIV (BASHH)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

March 26, 2019

Guidelines on the use of HIV pre-exposure prophylaxis (PrEP) were released in March 2019 by the British HIV Association (BHIVA)/British Association for Sexual Health and HIV (BASHH).[1]

PrEP Recommendations in Men Who Have Sex With Men (MSM)

HIV‐negative MSM who are at an increased risk of HIV acquisition because of condomless anal intercourse in the preceding 6 months and ongoing condomless anal intercourse should be offered daily or on‐demand oral tenofovir disoproxil/emtricitabine (TD‐FTC) as PrEP.

HIV‐negative MSM engaging in condomless anal intercourse with a partner who is HIV-positive should be offered daily or on‐demand oral TD‐FTC as PrEP, unless the partner has been on antiretroviral therapy (ART) for at least 6 months and has a plasma viral load of <200 copies/mL.

PrEP Recommendations in Heterosexual Individuals

HIV‐negative heterosexual men and women engaging in condomless intercourse with a partner who is HIV-positive should be offered daily oral TD‐FTC as PrEP, unless the partner has been on ART for at least 6 months and has a plasma viral load of <200 copies/mL.

Heterosexual men and women with ongoing risk factors for HIV acquisition should be offered daily oral TD‐FTC as PrEP on a case‐by‐case basis.

Tenofovir disoproxil fumarate (TDF) alone can be offered to heterosexual men and women if FTC is contraindicated.

PrEP Recommendations in Trans Women

HIV‐negative trans women who are at an increased risk of HIV acquisition through condomless anal intercourse in the preceding 6 months and ongoing condomless intercourse should be offered daily oral TD-FTC as PrEP.

HIV‐negative trans women and trans men engaging in condomless intercourse with a partner who is HIV-positive should be offered daily oral TD‐FTC as PrEP, unless the partner has been on ART for at least 6 months and has a plasma viral load of <200 copies/mL.

PrEP Recommendations in Young People

HIV‐negative young MSM (aged 15-25 years) who are at an increased risk of HIV acquisition because of condomless anal intercourse in the preceding 6 months and ongoing condomless anal intercourse should be offered daily or on‐demand oral TD‐FTC as PrEP.

HIV‐negative young people engaging in condomless anal intercourse with a partner who is HIV-positive should be offered TD‐FTC as PrEP, unless the partner has been on ART for at least 6 months and has a plasma viral load of <200 copies/mL.

HIV‐negative young trans women who are at an increased risk of HIV acquisition because of condomless anal intercourse in the preceding 6 months and ongoing condomless anal intercourse should be offered daily oral TD‐FTC as PrEP.

Recommendations for Initiating and Discontinuing PrEP

If anal intercourse represents the HIV acquisition risk, PrEP can be initiated as a double-dose of TD‐FTC taken 2-24 hours before intercourse and continued daily until 48 hours following the last sexual risk.

If PrEP for anal intercourse has been interrupted but less than 7 days have elapsed since the last TD‐FTC dose, PrEP can be re‐initiated with a single dose of TD‐FTC.

If vaginal intercourse represents the risk for HIV acquisition, PrEP should be initiated as a daily regimen 7 days before the likely exposure risk and continued daily for 7 days following the last sexual risk.

Recommendations for Baseline Testing

Baseline HIV testing with a combined antigen/antibody serology test should be performed before PrEP is initiated.

Same‐day PrEP initiation may occur in individuals who have a negative result on a third‐generation or higher blood‐based point‐of‐care test (POCT) on the same day or a negative result on a combined HIV antigen/antibody test within the preceding 4 weeks.

HIV viral load should be considered if a high‐risk exposure has occurred within the preceding 4 weeks.

PrEP should be deferred until an HIV RNA result is available in individuals who report condomless anal intercourse in the preceding 4 weeks and who have symptoms that suggest HIV seroconversion.

Baseline hepatitis B virus (HBV) screening should be performed in individuals with unknown HBV status, and vaccination should be initiated in nonimmune persons.

A specialist in viral hepatitis/coinfection should assess patients with evidence of chronic HBV infection to decide whether to continue or to terminate therapy.

On‐demand PrEP dosing should not be offered to individuals with chronic HBV infection.

MSM and other individuals at risk for hepatitis C virus (HCV) infection should undergo baseline HCV screening.

A full baseline sexually transmitted infection (STI) screen should be performed, including syphilis serology and nucleic acid amplification testing (NAAT) for gonococcal and chlamydial infection at exposure sites (genital, rectal, pharyngeal).

Baseline renal function should be assessed with serum creatinine testing, estimated glomerular filtration rate (eGFR), and urinalysis; PrEP can be initiated while results are pending.

The eGFR should be >60 mL/min/1.73 m2 in persons starting TDF. If the eGFR is less than this, PrEP should be considered on a case-by-case basis.

Suboptimal Adherence to PrEP

If fewer than 4 doses of the daily PrEP regimen are taken per week, it is unlikely to be effective. Despite this, no evidence has shown that 4 instead of 7 doses per week is adequate.

Recommendations for Monitoring During PrEP

Individuals on PrEP should undergo HIV testing every 3 months with a laboratory combined HIV antigen/antibody test or a blood‐based POCT.

Individuals on PrEP with symptoms that suggest HIV seroconversion should undergo combined HIV antigen/antibody testing and HIV viral load testing.

If primary HIV infection is confirmed, baseline resistance testing should be performed to evaluate for evidence of resistance‐associated mutations to tenofovir or emtricitabine, along with other mutations.

All individuals on PrEP should undergo screening for bacterial STIs every 3 months. MSM, trans women, and others with an ongoing HCV risk should also undergo HCV testing every 3 months.

Recommendations for Terminating PrEP

PrEP should be discontinued if an HIV test shows a positive result, and the patient should be immediately referred to an HIV specialist.

Suboptimal adherence to PrEP is a relative contraindication to continued use.

HBV infection should be excluded prior to discontinuing TD‐FTC in patients without vaccine-induced immunity.

For more information, please go to Preexposure HIV Prophylaxis.

For more Clinical Practice Guidelines, please go to Guidelines.

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