Building a good understanding of the underlying social context is a fundamental prerequisite to delivering effective and compassionate PrEP care.
Counseling on PrEP is naturally a sensitive topic as it broaches personal information and socially controversial issues. There are many ways to medically discuss the components of care with a patient. Similar to the subtleties mentioned in the section on how to take a sexual and substance use history, the counseling involved during PrEP initiation requires a mindful approach. Minor adjustments in our language may be critical in establishing a good rapport and ensuring proper patient understanding and follow-up care.
The inequities seen in PrEP make this point particularly important. The negative stigma that continues to be associated with HIV and issues related to medical mistrust are just some of the many reasons why PrEP is not being adequately delivered to those who need it most.
The style and approach in which you discuss PrEP is an ever-evolving process that will require trial and error. Continue refining your approach while including the following counseling points during your initial discussions of PrEP.
PrEP Initiation Patient Counseling Checklist
I have discussed ALL of the following points with the patient
Their risk of acquiring HIV and the benefits PrEP has to offer
When taken appropriately, PrEP offers more protection against HIV than condoms. 99% vs. 90%
Pinkerton, & Abramson, P.. (1997). Effectiveness of condoms in preventing HIV transmission. AIDS Weekly (p. 37–). NewsRX LLC.
PrEP is an optional medication used to prevent a condition (HIV) that will require medication therapy
Information about the 3 medication options for PrEP
PrEP can be started and stopped at anytime based on the patient’s preference (minding the HBV status)
For injectable cabotegravir (Apretude), discontinuation will require oral PrEP and lab monitoring every 3 months for a year after the last injection
All formulations of PrEP are well tolerated with side effects including: headache, insomnia, nausea, vomiting, diarrhea, rash, fatigue. Side effects occur in <5% of all patients.
Side effects of injectable cabotegravir (Apretude) also include minor injection site reactions.
All of these side effects are non-life threatening and typically resolve within the first month.
PrEP takes time to reach adequate levels to provide protection
For daily F/TDF (Truvada)
1 week of consecutive use to protect penile tissue and rectal tissue
3 weeks of consecutive use to protect cervicovaginal tissue and the bloodstream
ED-PrEP using F/TDF (Truvada)
2 pills 2-24 before sex and 1 pill every 24 hours for 48 hours after last sexual activity
No data is available for F/TAF (Descovy) or CAB (Apretude); similar counseling to F/TDF
PrEP does NOT protect against STIs
Barrier methods and routine testing encouraged
PrEP does not prevent pregnancy
Discussed options for contraception and family planning
PrEP care requires laboratory testing and follow-up
For daily F/TDF (Truvada), daily F/TAF (Descovy), or ED-PrEP with F/TDF (Truvada) Follow-up in 1 month then follow-up with labs every 3 months.
For CAB (Apretude) Follow-up in 1 month with labs then follow-up with labs every 2 months
PrEP can typically be provided completely free of charge