In 2019, 38 million people were living with HIV worldwide. Despite a global reduction of 23% in new infections and a decline of 39% in deaths compared with 2010, an increase of 49% in new diagnoses was seen in high-risk groups in Europe.1 Better prevention strategies are needed to avoid future infections.
Pre-exposure prophylaxis (PrEP) has been recommended by the WHO since 2015, in addition to other preventative measures such as early diagnosis and treatment of HIV and STIs, and risk reduction strategies.2 A 35% reduction in the number of new HIV diagnoses was seen among men who have sex with men (MSM) after the introduction of PrEP.3
Prescribing PreP requires an individualised approach to assess current and future risk of HIV and should be discussed with all sexually active individuals, not only those recommended in current guidelines.4 This includes adolescents, and heterosexual women in Africa, as well as people who inject drugs.5
PrEP treatment options include oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC)or tenofovir alafenamide/emtricitabine(TAF/FTC) for MSM, and a dapivirine vaginal ring.(5,6,7) Long-acting intramuscular injections of cabotegravir may be another option for MSM and TGW.8 Other formulations are currently being investigated, including neutralising antibodies and long-acting oral or parenteral agents.
In the clinic, the first visit should include a comprehensive medical history. A negative result in a 4thgeneration antigen/antibody HIV test in advance is key to avoid starting PrEP in someone with HIV. STI tests need to be reviewed and HIV prevention and PrEP dosing regimens discussed. A repeat HIV test is needed after one month and subsequently every three months. PrEP is very effective and a positive test usually indicates non-adherence, meaning fewer than 4 doses/week for MSM and TGW or 6 doses/week for heterosexual individuals and drug users. A patient education programme is critical for risk reduction strategies and PrEP adherence. At every visit, it is important to discuss if the patient wishes to continue and what regimen would suit them best.