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11/13/24, 8\:19 PM Guide | PrEP counselling

PrEP counselling

Table of contents

Background

Indications for PrEP

PrEP is recommended in the following groups\:
Men who have sex with men (MSM) or trans women reporting condomless sex in the last 6 months and ongoing condomless
anal sex.
Anyone reporting condomless sex with someone who is known to be HIV positive, unless the partner has been on
antiretroviral therapy (ART) for at least 6 months and their plasma viral load is \<200 copies/mL.
PrEP should be considered for other patients on an individual basis.
There are many risk factors that should be taken into consideration including\:
Reporting future anticipated high-risk sexual behaviour
Bacterial rectal sexually transmitted infection (STI) or hepatitis C (HCV) in the previous year
Use of post-exposure prophylaxis (PEP) in the previous year
Feeling unable to negotiate and/or use condoms
Condomless sex with high-risk populations
Injecting recreational drug use/sharing drug-taking equipment

Contraindications to PrEP

PrEP should not be taken by people who are HIV positive.
It is therefore important to ask about any recent episodes of condomless sex and subsequent seroconversion symptoms. PrEP
is usually not required in those that report consistent condom use. PrEP is also often unnecessary if the patient only engages in
sexual activity with HIV positive partners who are on treatment and have an undetectable viral load.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Clarify the purpose of the consultation\:
t h a t c o r r e c t ?"
" I b e l i e v e t h a t y o u w o u l d l i k e t o d i s c u s s p r e-e x p o s u r e p r o p h y l a x i s t o d a y / P r E P t o d a y , i s
It is important to establish rapport and an open line of communication\:
c l e a r l y e x p l a i n e d s o m e t h i n g p l e a s e f e e l f r e e t o i n t e r r u p t m e s o t h a t I c a n c l a r i f y .
"
" I f a t a n y p o i n t y o u h a v e q u e s t i o n s o r f e e l t h a t I h a v e n o t

Ideas, concerns & expectations

An important part of counselling is eliciting and exploring a patient’s ideas, concerns, and expectations.
Asking about a patient’s ideas, concerns, and expectations can allow you to gain insight into how a patient currently perceives
their situation, what they are worried about and what they expect from the consultation. It can sometimes be challenging to use
the ICE structure in a way that sounds natural in your consultation, but we have provided some examples for each of the three
areas below.
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Ideas
“ W h a t d o y o u k n o w a b o u t P r E P s o f a r ?”
“ H a v e y o u r e a d o r h e a r d a b o u t P r E P b e f o r e ?”
“ W h a t a r e y o u r t h o u g h t s a b o u t P r E P ?”
Concerns
“ I s t h e r e a n y t h i n g t h a t w o r r i e s y o u a b o u t t a k i n g P r E P ?”
Expectations
“ W h a t w e r e y o u h o p i n g t o g e t f r o m o u r d i s c u s s i o n t o d a y ?”
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , y o u w o u l d l i k e m e t o c o v e r t o d a y ?”

What is PrEP?

PrEP or pre-exposure prophylaxis is a combination of two antiretroviral drugs, Tenofovir DF and Emtricitabine. These drugs
have been widely used to treat HIV for many years. They work by preventing HIV from multiplying in T cells.
There have been multiple trials assessing the e
infection in those prescribed PrEP versus those not.
PrEP reduces the chance of being infected with HIV via sexual intercourse by up to 99% if it is taken as prescribed.
Example
“ P r E P s t a n d s f o r p r e-e x p o s u r e p r o p h y l a x i s . y o u f r o m b e i n g i n f e c t e d w i t h H I V .
”
“ I t i s a c o m b i n a t i o n o f t w o m e d i c a t i o n s w h i c h s t o p t h e v i r u s i n f e c t i n g y o u r c e l l s . H I V f o r a l o n g t i m e .
”
“ S t u d i e s h a v e s h o w n t h a t i f P r E P i s t a k e n r e l i a b l y , b y u p t o 9 9 % .
”
I t i s a m e d i c a t i o n t h a t y o u t a k e b e f o r e a n d a f t e r s e x w h i c h c a n h e l p p r e v e n t
W e h a v e b e e n u s i n g t h e s e d r u gs t o t r e a t
i t r e d u c e s t h e c h a n c e o f b e i n g i n f e c t e d w i t h H I V v i a s e x u a l i n t e r c o u r s e

How to take PrEP

There are two ways in which PrEP can be taken. The
second is by taking tablets prior to and after sexual contact, which is known as event-based dosing.

Daily dosing

Most studies of PrEP were conducted using the daily dosing method. Daily dosing involves taking PrEP every day.
Taking PrEP every single day results in a consistent level of protection from HIV infection at all times provided it is taken
correctly. This means that sexual encounters are not something that would need to be planned for.
Daily dosing is appropriate for anyone who is starting PrEP.
The time to protection varies depending on the type of sex\:
Anal sex\: initial protection is provided by taking two pills 2 to 24 hours before sex and then one subsequent pill at 24 and 48
hours after (as with event-based dosing described below). A daily pill from 72 hours onwards then provides future protection,
as long as there is no break.
Vaginal sex\: the time to clinical protection is 7 days of daily dosing.

Event-based dosing

Event-based dosing involves taking PrEP before sex and for a period after sex.
It is appropriate for anal sex and men having insertive vaginal sex. However, if a patient is taking more than four tablets a week
on a regular basis, daily dosing may be a simpler option.
https\://app.geekymedics.com/osce-guides/counselling/prep-counselling/ 2/611/13/24, 8\:19 PM Guide | PrEP counselling
Event-based dosing is contraindicated in anyone having receptive vaginal sex or with a current hepatitis B infection.
For event-based PrEP to be e
Two tablets between 2 and 24 hours before sex
A single pill 24 hours after the
Another pill 24 hours after the second dose
Therefore, a double dose should be taken prior to sex. Then a single dose again at both 24 and 48 hours.
If a patient is planning to have sex multiple times over a period of more than 24 hours, they should continue to take PrEP every
24 hours until 48 hours have passed since the last episode of sex.
If a patient plans to have sex less than a week after they last
double dose.

Side e

Common side e
usually settle within the
Occasionally PrEP can cause more serious side e
When this does occur, it tends to be mild, non-progressive, and reversible.
Small decreases in bone density have also been noted in some patients taking PrEP, but there is no evidence of increased
fracture risk.
Example
“ A s w i t h a l l m e d i c a t i o n s , t h e r e i s a r i s k o f p o t e n t i a l s i d e e
”
n a u s e a , o r a n u p s e t
“ T h e r e i s a c h a n c e t h a t P r E P c a n a
r e g u l a r u r i n e a n d b l o o d t e s t s . I f t h e r e a r e a n y i s s u e s , t h e s e t y p i c a l l y r e s o l v e a f t e r s t o p p i n g t h e m e d i c a t i o n .
”

Monitoring

Before starting PrEP several baseline tests are required along with regular monitoring every three months.

HIV testing

PrEP can only be taken if an individual is HIV negative.
The drugs used in PrEP are also used to treat HIV. However, when treating HIV, a combination of drugs is used. This means PrEP
would only partially treat a HIV infection, putting the individual at risk of developing resistance to medications.
Fourth-generation HIV tests have a window period of 45 days. If a patient has had condomless sexual intercourse within the
last 45 days, they can start PrEP if they are at high risk of contracting HIV providing they have no symptoms of seroconversion
illness and are aware of the potential risk.
However, patients should be asked to return as soon as they are outside of the window period for a repeat HIV test.
For all patients, a repeat HIV test should be performed every 3 months throughout treatment.

Hepatitis B

Tenofovir, one antiviral within PrEP can also be used to treat hepatitis B. Should a patient test positive for HBV they can take
daily PrEP under the supervision of a hepatology service. However, event-based dosing would not be an option. This is
because withdrawal of PrEP in HBV positive individuals can cause rebound viraemia and fulminant liver damage. All HBV
negative individuals should be o
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Renal function

Given that PrEP can a
annually. A urine dipstick to check for protein should be performed every three months and if positive followed up with
additional U&Es.

Routine STI testing

Routine STI testing is recommended every three months in all patients, but particularly those who have had multiple sexual
partners in the previous window.
Routine STI screening involves testing for\:
Chlamydia
Gonorrhoea
Syphilis
HIV
Hepatitis C\: for individuals identi
Hepatitis A\: for at-risk individuals, a vaccine is also available
For more information, see the Geeky Medics guide to sexually transmitted infections.
Example
“ B e f o r e y o u s t a r t P r E P i t i s i m p o r t a n t w e d o s o m e b a s e l i n e b l o o d t e s t s t o e n s u r e t h a t i t i s s a f e f o r y o u t o t a k e i t .
”
“ I f y o u s t a r t P r E P a n d a l r e a d y h a v e H I V i t c a n l e a d t o t h e v i r u s b e c o m i n g r e s i s t a n t t o t h e m e d i c a t i o n . T h i s m e a n s t h a t
s o m e o f t h e d r u g s w e m i g h t u s e t o t r e a t w o u l d n o t w o r k a s w e l l .
”
“ W e n e e d t o d o a b l o o d t e s t t o l o o k f o r a v i r u s c a l l e d h e p a t i t i s B . I f y o u w e r e f o u n d t o b e i n f e c t e d w i t h h e p a t i t i s B , e v e n t-
b a s e d d o s i n g w o u l d n’ t b e s u i t a b l e f o r y o u a n d w e w o u l d n e e d t o s e e k a d v i c e f r o m t h e l i v e r t e a m a b o u t t r e a t m e n t . I f y o u
a r e f o u n d t o n o t b e i n f e c t e d w i t h t h e h e p a t i t i s B v i r u s , w e c a n o
”
“ W e k n o w t h a t o c c a s i o n a l l y P r E P c a n a
w o r k i n g t o d a y s o w e c a n q u i c k l y i d e n t i f y a n y d e t e r i o r a t i o n i n t h e f u t u r e .
”
“ W e r e c o m m e n d t h a t e v e r y b o d y w h o i s s e x u a l l y a c t i v e g e t s a r e g u l a r s e x u a l h e a l t h s c r e e n e v e r y 3 m o n t h s , t h e y a r e h a v i n g c o n d o m l e s s s e x .
”
e s p e c i a l l y i f

Missed pills

PrEP is most e
patients to adhere to treatments. However, missed doses can easily happen and so patients should be advised to seek advice
should this occur.

Daily dosing

If one or two doses are missed, then this is not an issue providing it has been taken consistently for at least seven days.
However, repeatedly missed doses result in a decreased level of protection. Studies show that if a patient misses three doses
in a one-week period, protection drops to 96%. This falls further to 76% if
If a patient has missed more than seven pills in a row they should restart with a double dose and then continue with a single
dose from the next day onwards.

Event-based dosing

If the
patient should also be advised to contact their local clinic or emergency department to discuss the need for post-exposure
prophylaxis (PEP).
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Example
“ I f y o u m i s s a p i l l o c c a s i o n a l l y t h i s s h o u l d n o t c a u s e a n i s s u e p r o v i d i n g y o u h a v e t a k e n i t c o n s i s t e n t l y f o r a t l e a s t o n e w e e k
p r i o r . H o w e v e r , i f y o u a r e m i s s i n g m u l t i p l e p i l l s i n a w e e k t h e n y o u w i l l n o t b e a s w e l l p r o t e c t e d . I f t h i s i s t h e c a s e p l e a s e
c o n t a c t u s a s y o u m a y b e e l i g i b l e f o r p o s t-e x p o s u r e p r o p h y l a x i s w h i c h i s a l s o k n o w n a s P E P .
”
“ I f y o u f o r g e t t o t a k e y o u r d o u b l e d o s e b e f o r e s e x u a l c o n t a c t , d o s e e a c h d a y a f t e r w a r d s . A n y P r E P i s b e t t e r t h a n n o P r E P . d o c t o r a s y o u m a y n e e d P E P .
"
t a k e i t a s s o o n a s y o u r e m e m b e r a n d c a r r y o n w i t h a s i n gl e
H o w e v e r , i f t h i s d o e s h a p p e n , w e r e c o m m e n d c o n t a c t i n g a

PrEP in speci

Whilst PrEP is most commonly used amongst men who have sex with men, it is also suitable for numerous other groups who
may have slightly di
Speci
PrEP will not a
Studies have not shown any pregnancy complications from PrEP. However, the sample sizes were small so women should
be encouraged to speak with their doctor.
Daily PrEP can be used safely when breastfeeding.
Speci
If having vaginal sex daily dosing is needed.
If only having anal sex then event-based dosing can also be used.
PrEP will not a

Closing the consultation

Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the
consultation.
Finally, thank the patient for their time and o
Dispose of PPE appropriately and wash your hands.
Example
“ B e f o r e w e
w o r k s , h o w t o t a k e i t , w h a t t o d o i f y o u m i s s a d o s e , c o m m o n s i d e e
y o u f e e l w e h a v e m i s s e d ? O r a n y t h i n g e l s e y o u w o u l d l i k e t o a s k ?”

Reviewer

Dr Andrew Tomkins
Consultant in Genitourinary Medicine
North Manchester General Hospital

References

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-G. ., Kallas, E.G. and Grant, R.M.
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(2012). Emtricitabine-Tenofovir Concentrations and Pre-Exposure Prophylaxis E
S c i e n c e T r a n s l a t i o n a l M e d i c i n e , [online] 4(151), pp.151ra125–151ra125. Available from\: [LINK]
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u s e o f H I V p r e-e x p o s u r e p r o p h y l a x i s ( P r E P ) 2 0 1 8 . [online] Available from\: [LINK]
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(2019). Risk of HIV transmission through condomless sex in serodi
suppressive antiretroviral therapy (PARTNER)\:
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Source\: geekymedics.com
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