Same-Day Oral PrEP Quick Guide
Updated 3.1.2023
Purpose: To provide PrEP on the same day a patient expresses interest in starting PrEP. Studies have shown that same-day prescriptions are safe and associated with significantly higher levels of PrEP uptake compared to postponing prescriptions to subsequent visits.
Ask 3 screening questions to assess safety for PrEP:
- Symptoms of acute HIV: “Have you had any of the following symptoms today or in the past 30 days: a fever with sore throat, rash, swollen lymph nodes, or headache?”
- If YES: order HIV RNA Viral Load + 4th gen HIV Ag/Ab and await results before prescribing PrEP.
- History of kidney disease: “To your knowledge, do you have any history of kidney problems or kidney disease?”
- If YES: order serum Cr (eGFR) and await results before prescribing oral PrEP.
- Known hepatitis B virus infection: “Do you have, or have you ever been told that you have hepatitis B infection?”
- If YES: order hep B surface antigen (HBV sAg) and await results before prescribing oral PrEP. If the HBV sAg is positive, it’s OK to start PrEP with plan for safe discontinuation of PrEP in the future; abrupt discontinuation can cause flare of hepatitis B infection.
Perform same-day rapid HIV testing to document negative status on day of PrEP initiation.
- Ensure negative result on a blood-based point-of-care rapid HIV Ab test (rapid HIV Ag/Ab preferred). Oral fluid HIV tests should be avoided, as they are less sensitive for the detection of acute/recent HIV infection.
Order remaining lab tests to be obtained on day of PrEP start (or as soon as possible within 7 days*):
- 4th gen HIV Ag/Ab testing
- HIV RNA viral load (if history of any PrEP use in the last 6 months)
- Baseline Cr (eGFR) – eGFR must be ≥60 for F/TDF or ≥30 for F/TAF
- Hep B surface antigen (HBV sAg) – if positive, ok to continue daily oral PrEP but must make a plan for safe discontinuation as stopping F/TDF or F/TAF can lead to hepatitis B viral flare.
- Lipid panel (for F/TAF only)
- STI testing: syphilis serology (RPR/VDRL), GC/CT at all sites of exposure, hepatitis C Ab
- Urine pregnancy test (UPT) for patients who can become pregnant – encourage continued use of PrEP to prevent HIV transmission throughout pregnancy if UPT is positive and patient has ongoing risk of acquiring HIV.
*Obtaining lab-based testing within 7 days of PrEP start is acceptable for oral PrEP only; ensure method available to contact the patient immediately for positive lab results.
Prescribe or dispense PrEP immediately:
- 30-day supply of F/TDF (preferred) or F/TAF as second line option for those assigned male at birth)
- ICD-10 billing code for HIV PrEP: Z20.6 (“exposure to HIV”) or Z20.2 (“exposure to STD”)
Daily Oral PrEP Initiation and Follow up Protocol
| PrEP initiation visit | Follow-up visits (every 3 months) | |
|---|---|---|
| HIV status | • HIV Ag/Ab test (lab-based preferred) | • HIV-1 qualitative RNA (viral load) and HIV Ag/Ab test. |
| Renal status | • eGFR ≥60 ml/min to safely use F/TDF. ≥30 ml/min to safely use F/TAF. | • Assess every 6 months if baseline age≥ 50 years or eGFR <90 ml/min. • Otherwise assess every 12 months. |
| STI infection status | • Syphilis serology for all GC/CT at all sites of exposure. | • Repeat STI screen every 3 months. |
| Lipid screen | • F/TAF only | • Repeat every 12 months for F/TAF only. |
| Screen for active HBV | • Hep B sAg | • If not done at initiation visit. |
| Prescription | • 90-day supply | • 90-day refill if HIV test is negative. |
| Discontinuation | • Continue for 7 days after last potential exposure. |