Page 77 - HIVMED_v21_i1.indb

Page 4 of 8 Guideline

Step 3: Check general well-being: Clinical assessment: A • Immediate access to antiretroviral therapy (ART) for
clinical assessment for STIs should be performed at initiation, potential PrEP users who screen HIV-positive and require
6 monthly or when indicated. treatment.
• Appropriate STI screening is recommended and aetiologic • A prescription for PrEP (or PrEP medication) should be
testing and treatment should be provided when available. provided for a 3-month start.
This should include nucleic acid antigen testing for • Adolescents and younger users or those who have
Chlamydia trachoma and Neisseria gonococcus and serology identified pill-taking difficulties may be invited to return
for Treponema pallidum. after 1 month to troubleshoot adherence difficulties.
• Syndromic STI screening and management is otherwise • Telephonic contact may help with mild side effect
recommended. management and difficulties with establishing pill-taking
• Viral hepatitis B screening is recommended at PrEP routines.
initiation and screening if status is unknown. • A follow-up visit for clinical monitoring, counselling on
• Hepatitis B vaccination is recommended if available or if persistence at 3 months, and then every 6 months or as
screening serology test is negative. required. Again, younger users may benefit from more
regular contact.
Step 4: Check for contraindications: Renal function: A
baseline assessment of renal function should be performed Tips to support pre-exposure prophylaxis pill-taking
(creatinine and eGFR) in patients who are above 40 years of • Schedule medication taking time to correspond with the
age, have co-morbidities or are on concomitant medication.
Pre-exposure prophylaxis should not be used in people client’s daily routine activities (e.g. brushing teeth, eating
with a baseline eGFR of < 50 mL/min. Renal function may breakfast and going to bed).
be checked annually and more frequently as dictated by an • Take pills at night if worried about side effects (e.g. in
underlying renal problem or comorbidity. pregnant women).
• Use reminders, for example, cell phone, alarms, beepers
Step 5: Plan follow-up visits: and calendars .
• Use pillboxes to ensure daily use.
• Assess how pill-taking is going for PrEP user . • Review disclosure issues to identify those who can
• Interactions should be supportive and affirming. support the client’s intentions to take their pills or barriers
• Identify a motivator to support effective pill-taking . to pill-taking because of lack of disclosure or privacy at
• Provide PrEP education regarding effective use and home .
effectiveness of PrEP. • Join an online support group, for example, Facebook:
• Identify barriers to effective use. PrEP Rethinking HIV Prevention.
• Provide realistic strategies to address barriers.
• Discuss use of other HIV prevention measures that are Other considerations
relevant to situation . Stopping and starting pre-exposure prophylaxis: Unlike
• Review need for PrEP and any change in sexual risk.
taking ART, PrEP is not a lifelong intervention and individuals
should be encouraged to ascertain risk and gauge their own
Step 6: Package of prevention: Providers can provide PrEP
on the same day as counselling, following HIV testing. need for PrEP. Different types of prevention may also be
Pre-exposure prophylaxis alone provides high levels of preferred at different times, for example, a holiday away
HIV prevention; however, additional benefits are likely to versus busy working period at home.
accrue if it is offered as part of a package of combination
prevention that includes: Individuals should be instructed how to begin and stop daily
use PrEP.
• Counselling on effective use, starting and stopping PrEP.
• Agreement for follow-up HIV testing.
• Human immunodeficiency virus testing and counselling This is different from ‘on-demand’ PrEP, which is described
of sex partners (including HIV self-screening) in more detail below.
• Commodities such as condoms and sexual lubricants.
• Sexual health screening, including STI symptom check, Tenofovir disoproxil fumarate/FTC can only prevent HIV if
aetiological STI testing if available and treatment either provided at sufficient levels in the tissues at the time of HIV
syndromically or as per laboratory results. exposure. The need for loading doses has been controversial
• Discussions on reproductive intent and provision of and largely informed by PK modelling studies. The current
contraception as needed. research suggests that as many as 7 days of oral doses may be
• Active safer conception counselling and guidance should required in the case of vaginal mucosal exposure to ensure
be offered to women and couples who wish to conceive that sufficient tissue levels have been reached. However,
(see safer conception guidelines). clinical use in cis-males and trans-women suggests that high
• Gender affirming counselling and treatment for TG levels of protection can be achieved with dosing just before
populations. exposure.

http://www.sajhivmed.org.za 69 Open Access