Abstract
The Southern African HIV Clinicians Society published its first set of oral pre-exposure prophylaxis (PrEP) guidelines in June 2012 for men who have sex with men (MSM) who are at risk of HIV infection. With the flurry of data that has been generated in PrEP clinical research since the first guideline, it became evident that there was a need to revise and expand the PrEP guidelines with new evidence of safety and efficacy of PrEP in several populations, including MSM, transgender persons, heterosexual men and women, HIV-serodiscordant couples and people who inject drugs. This need is particularly relevant following the World Health Organization (WHO) Consolidated Treatment Guidelines released in September 2015. These guidelines advise that PrEP is a highly effective, safe, biomedical option for HIV prevention that can be incorporated with other combination prevention strategies in Southern Africa, given the high prevalence of HIV in the region. PrEP should be tailored to populations at highest risk of HIV acquisition, whilst further data from studies in the region accrue to guide optimal deployment to realise the greatest impact regionally. PrEP may be used intermittently during periods of perceived HIV acquisition risk, rather than continually and lifelong, as is the case with antiretroviral treatment. Recognition and accurate measurement of potential risk in individuals and populations also warrants discussion, but are not extensively covered in these guidelines.
Highlights
Pre-exposure prophylaxisPre-exposure prophylaxis (PrEP) involves taking a pharmaceutical agent prior to an exposure to prevent an outcome
pre-exposure prophylaxis (PrEP) for HIV involves the use of antiretroviral (ARV) medications to prevent HIV infection
Tenofovir (TDF) and tenofovir/emtricitabine (TDF/FTC) in a single tablet fixed-dose combination (FDC) are the oral ARV agents used in oral PrEP studies to date
Summary
Pre-exposure prophylaxis (PrEP) involves taking a pharmaceutical agent prior to an exposure to prevent an outcome (e.g. infection by a microbe, such as malaria). PrEP for HIV involves the use of antiretroviral (ARV) medications to prevent HIV infection. The present guidelines support the use of TDF/FTC in combination for effective PrEP. An initial three-drug post-exposure prophylaxis (PEP) approach may be used whilst confirming HIV-negative status in an individual presenting with acute viral symptoms and a concomitant history of recent potential HIV exposure. Headache and gastrointestinal symptoms with weight loss are relatively common usually mild and self-limiting, occurring for the first 4–8 weeks after initiating PrEP These can be managed with counselling support and provision of symptomatic relief. PrEP, if taken correctly and consistently, will offer protection from HIV infection but not from other STIs or pregnancy, and clinicians should continue to support PrEP users to be aware of STI symptoms and other components of combination prevention. Recommendations for the use of PrEP among other at-risk individuals, and the components of these recommendations, will be informed by future evidence
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