Primary prevention
Condoms
The most widely available tool for prevention of HIV from sexual exposure is the male condom. Male condoms afford a high degree of protection: consistent and correct male condom use reduces HIV transmission by more than 90%.[39] Numerous studies have shown that the female condom is an acceptable method for many women and men, and is a valuable alternative for women whose partners refuse to use male condoms. Unlike the male condom, the female condom can be inserted some time before sex, and does not depend on the same degree of male cooperation for its successful use.
Oral pre-exposure prophylaxis (PrEP)
PrEP is an antiviral regimen that people who are at risk of HIV take to prevent HIV. Use of oral PrEP has increased significantly, particularly among gay men and other men who have sex with men (MSM).[40][41]
Studies have shown the effectiveness of daily oral PrEP in reducing the risk of HIV in adults who are at high risk for HIV. [
]
Evidence from randomized controlled trials shows that oral tenofovir disoproxil/emtricitabine prophylaxis is highly effective in reducing the risk of HIV acquisition (75% to 86% reduction in the risk of HIV in MSM, depending on adherence level), and is considered safe with minimal adverse effects, in MSM, serodiscordant couples, and people who inject drugs.[42][43]
However, data from observational studies found that efficacy appears to be lower in real-world settings (60% reduction in the risk of HIV overall), possibly due to suboptimal PrEP adherence and interruptions to treatment supply, particularly among people <30 years of age and those in certain socioeconomic groups.[44]
The largest real-world study involving over 24,000 trial participants at sexual health clinics and conducted over three years found that the use of oral PrEP reduced the risk of getting HIV by 86% in real-world settings.[45]
A systematic review, including 20 randomized controlled trials with over 36,000 participants, found that oral PrEP was associated with a decreased risk of acquiring HIV in adults at increased risk of HIV acquisition, compared with placebo or no PrEP.[46]
There are data that provide reassurance that resistance is unlikely to occur in patients taking PrEP.[47]
Guideline recommendations for the use of oral PrEP vary. Consult your local guidelines for further information.
The World Health Organization strongly recommends offering oral PrEP (containing tenofovir disoproxil) as an additional prevention choice to people who are at substantial risk of HIV, as part of combination prevention approaches, based on high-certainty evidence.[48]
The Centers for Disease Control and Prevention (CDC) recommends daily oral PrEP with tenofovir disoproxil/emtricitabine as a prevention option for: sexually active adults who report sexual behaviors that place them at substantial ongoing risk of HIV exposure and acquisition; and adults who inject drugs and report injection practices that place them at substantial ongoing risk of HIV exposure and acquisition. However, all sexually active adults should be informed about PrEP for prevention of HIV acquisition. Tenofovir disoproxil is recommended for both men and women; however, tenofovir alafenamide is recommended in men and transgender women only.[49] Long-term safety and tolerability of tenofovir alafenamide in cisgender men and transgender women has been demonstrated up to 144 weeks.[50] The efficacy of tenofovir alafenamide/emtricitabine has not been demonstrated in people with receptive vaginal exposure.[51] The safety and efficacy of other daily oral antiretroviral drugs for PrEP have not been studied extensively and are not currently recommended. HIV status should be assessed at least every 3 months so that people with incident infection promptly switch to treatment with antiretroviral therapy (ART).[49]
The American College of Obstetricians and Gynecologists (ACOG) supports CDC guidance, and recommends that obstetricians and gynecologists discuss PrEP with all sexually active adults, not only those who are considered to be a substantial risk of HIV.[52]
The US Preventive Services Task Force recommends oral PrEP (i.e., tenofovir disoproxil/emtricitabine) in high-risk adults. This includes sexually active adults who have engaged in anal or vaginal sex in the past 6 months and have any of the following: a sexual partner who has HIV; a bacterial sexually-transmitted infection in the past 6 months; a history of inconsistent (or no) condom use with sex partner(s) whose HIV status is unknown. It also includes people who inject drugs and have a drug-injecting partner who has HIV or shares injection equipment. People who engage in transactional sex and transgender women should be considered for PrEP based on these criteria.[53]
Acute and chronic HIV must be excluded by symptom history and HIV testing immediately before any PrEP regimen is prescribed. Renal function should be assessed at baseline and monitored periodically during treatment.[49]
Regular STI testing and risk reduction counseling is recommended for those who use PrEP.[49]
In some studies, a rapid increase in the use of PrEP has resulted in an equally rapid decrease in consistent condom use.[54]
PrEP use among MSM may be indirectly associated with an increased risk of bacterial STIs as PrEP users have more anal sex partners and are more likely to engage in condomless anal sex.[55]
Doxycycline postexposure prophylaxis (doxy PEP) may be offered to gay, bisexual, and other men who have sex with men or transgender women who have had a bacterial STI (specifically syphilis, chlamydia, or gonorrhea) diagnosed in the past 12 months, in order to prevent these infections. Doxy PEP is self-administered within 72 hours of having oral, vaginal, or anal sex.[56]
It should be noted that there has been a case report of tenofovir-susceptible, emtricitabine-resistant HIV acquisition despite high adherence to PrEP.[57][58]
PrEP did not significantly increase the risk of drug resistance mutations compared to placebo in one systematic review and meta-analysis.[59]
Consult your local drug information source for more information before prescribing oral PrEP.
Long-acting injectable PrEP
Cabotegravir extended-release injectable suspension is approved for use in at-risk adults for pre-exposure prophylaxis to reduce the risk of sexually-acquired HIV.[60]
Injections are administered every 2 months after the initial dose (two injections one month apart).
Patients can either start on intramuscular cabotegravir or take oral cabotegravir before switching to the intramuscular formulation to assess their tolerance of the drug.
A negative HIV test is required before treatment is started, and before each injection, in order to reduce the risk of developing drug resistance.
Long-acting injectable PrEP may address issues with adherence, and is an important prevention intervention for certain HIV populations.[61]
Long-acting injectable cabotegravir was found to lower HIV incidence compared to daily oral tenofovir disoproxil/emtricitabine when used for PrEP among men who have sex with men, transgender women, and cisgender women in sub-Saharan Africa in clinical trials.[62]
A systematic review and meta-analysis, which included four multisite randomized controlled trials, demonstrated a 70% risk reduction in HIV risk with long-acting injectable cabotegravir compared with daily oral PrEp.[63]
Guideline recommendations vary.
The WHO recommends long-acting cabotegravir as an additional prevention choice for people at substantial risk of HIV, as part of combination prevention approaches, based on moderate-certainty evidence.[64]
The Centers for Disease Control and Prevention recommends intramuscular cabotegravir injections as PrEP in adults who report sexual behaviors that place them at substantial ongoing risk of HIV exposure and acquisition.[49]
The US Preventive Services Task Force recommends intramuscular cabotegravir injections as an option for PrEP in high-risk adults (see above for criteria).[53]
Hepatotoxicity has been reported in a small number of people receiving cabotegravir, although similar levels were found among those receiving placebo. Consider liver function testing before and during treatment, and do not initiate treatment in people with advanced liver disease or acute viral hepatitis. Discontinue use if hepatotoxicity is confirmed. There are limited data on the use of cabotegravir in patients with hepatitis B or hepatitis C virus infection, and caution is advised.[64]
Consult your local drug information source for more information before prescribing long-acting injectable PrEP.
Pericoital (on-demand) PrEp
Pericoital (on-demand) oral PrEP may be considered instead of daily PrEP in MSM who have infrequent sexual exposures.
On-demand oral PrEP has been found to be effective in MSM who are at a high risk of HIV. However, a post-hoc analysis of the ANRS IPERGAY trial found that on-demand PrEP was also effective in MSM who were at a lower risk of HIV (i.e., periods of less frequent sexual intercourse defined as 5 episodes per month), with a 100% relative reduction of HIV incidence reported compared with placebo.[65]
Dapivirine vaginal ring
The dapirivine vaginal ring is approved for use in some countries with high disease burden to reduce the risk of HIV, in combination with safer sex practices, when oral PrEP is not used, cannot be used, or is not available. It is not approved in the US, but is approved in Europe. The ring is placed in the vagina and slowly releases dapivirine over a period of 28 days.
Current evidence shows that vaginal dapivirine microbicide probably reduces HIV acquisition in women who have sex with men. Other types of vaginal microbicides have not shown evidence of an affect on HIV acquisition.[66] [
]
A systematic review of 18 randomized controlled trials in sub-Saharan Africa found that the dapivirine intravaginal ring reduced the risk of HIV transmission in women by 29%. Other microbicides had no effect.[67]
In a randomized, double-blind, placebo-controlled, phase 3 trial in sub-Saharan Africa, the dapivirine vaginal ring was associated with a lower rate of HIV acquisition compared with placebo.[68]
Guideline recommendations for the use of dapivirine vaginal ring vary. Consult your local guidelines for further information.
The WHO recommends the dapivirine vaginal ring may be offered as an additional prevention choice for women at substantial risk of HIV, and part of combination prevention approaches, based on moderate-certainty evidence.[69]
Consult your local drug information source for more information before prescribing the dapivirine vaginal ring.
Treatment as prevention
ART may be used to prevent HIV transmission. This is commonly known as undetectable=untransmittable (or U=U). Several large studies have shown that ART prevents HIV transmission in both heterosexual couples and MSM who maintain an undetectable viral load.[70][71][72][73][74][75]
Based on high-quality evidence, there is a negligible risk of sexual transmission of HIV when an HIV-positive sex partner adheres to ART and maintains a suppressed viral load <1000 copies/mL measured every 4-6 months. Sexual transmission of HIV has occurred when viral load was >200 copies/mL with ART or condoms alone were used, although the risk remains low and incidence of HIV transmission when viral load is 200 to 1000 copies/mL remains unclear.[76] One systematic review found that the risk of sexual transmission in people with viral loads between 200 copies/mL and 1000 copies/mL is almost zero.[77]
In light of this evidence, US guidelines currently recommend that physicians should inform patients that maintaining a HIV RNA level <200 copies/mL with ART prevents transmission to sexual partners. Another form of prevention should be used for the first 6 months of ART until an HIV RNA level of <200 copies/mL has been documented, with some experts recommending that sustained suppression is confirmed before assuming there is no risk of transmission.[78]
The Prevention Access Campaign has also released a consensus statement stating that the risk of HIV transmission from a person living with HIV who is on ART and has achieved undetectable viral load in their blood for at least 6 months is negligible to nonexistent. Prevention Access Campaign: consensus statement Opens in new window
Immediate initiation of ART is recommended for the HIV-positive partner of HIV-serodiscordant couples, to prevent HIV transmission.[70][78] [
]
Circumcision
Circumcision is associated with a reduction in HIV risk, and has been found to be protective for both homosexual and men who have sex with men.[79][80][81] [
]
Other harm reduction methods
Convincing evidence exists for the benefit of needle exchange and clean syringes in the setting of methadone clinics, termed "harm reduction," where HIV transmission risk is related to shared intravenous drug use equipment. In addition, the supply of HIV-free blood and blood products, as well as sterile needles and syringes for injections and universal precautions in hospitals, has much reduced nosocomial transmission of HIV.[82]
Vaccines
The table that follows summarizes recommendations for pre-exposure prophylaxis (PrEP) for the primary prevention of HIV taken from Centers for Disease Control and Prevention (CDC) clinical practice guidance.[49]
Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Adult without HIV and not currently taking PrEP; reports anal or vaginal sex in the past 6 months
Possible acute HIV infection must be ruled out on history, examination and laboratory tests for all patients in whom PrEP is being considered. Renal function must also be assessed before starting PrEP medication as it may affect choice of drug/dose.
All
Intervention
Inform about PrEP for prevention of HIV acquisition; consider PrEP following an HIV risk assessment
The recommendation to inform all sexually active people about PrEP is influenced by the fact that patients often do not disclose stigmatized sexual or substance use behaviors to their health care providers (especially when not asked about specific behaviors).
Taking a brief, targeted sexual history is recommended for all adult patients as part of ongoing primary care, in order to identify those at substantial risk of HIV acquisition who are more likely to achieve benefit from PrEP (see subpopulation groups below).
However, people may request PrEP because of concern about acquiring HIV but not feel comfortable reporting sexual or injection behaviors to avoid anticipated stigmatizing responses in health care settings.
For this reason, after attempts to assess patient sexual and injection behaviors, it is recommended that clinicians offer PrEP to all patients who request it, even when no specific risk behaviors are elicited.
Goal
To facilitate risk assessment and discussion around PrEP; prevent acquisition of HIV in those at increased risk
The aim of providing this information is to enable patients to both respond openly to risk assessment questions and to discuss PrEP with people in their social networks and family members who might benefit from its use.
With HIV positive partner with unknown or detectable ( ≥200 copies/mL) viral load
Intervention
Prescribe PrEP
PrEP for an HIV-uninfected patient is indicated if a sexual partner with HIV has not been virally suppressed, has been inconsistently virally suppressed, or if his/her viral load status is unknown.
PrEP regimens include:
Daily oral PrEP with tenofovir/emtricitabine
Tenofovir disoproxil/emtricitabine is suitable for both men and women.
Tenofovir alafenamide/emtricitabine is recommended in men and transgender women only at increased sexual risk (it has not been studied in women as yet).
Long-acting injectable PrEP with intramuscular cabotegravir
Suitable for HIV prevention in adults at increased sexual risk.
Daily oral tenofovir disoproxil/emtricitabine is most commonly prescribed for PrEP.
However, of the oral options, oral tenofovir alafenamide/emtricitabine is the recommended option for patients with renal impairment; it is indicated in patients with an estimated creatinine clearance of <60 mL/min but ≥30 mL/min.
Clinicians may preferentially recommend oral tenofovir alafenamide/emtricitabine for persons with previously documented osteoporosis or related bone disease but routine screening for bone density is not recommended for PrEP patients.
Cabotegravir injections may be appropriate for patients with significant renal disease (use caution), those who have had difficulty with adherent use of oral PrEP and those who prefer injections every 2 months to an oral PrEP dosing schedule.
For select patients, consider same day prescription of PrEP, providing the clinic is able to meet certain safety requirements including availability of point-of-care HIV testing. Same-day prescription may be a suitable approach for:
Those with time or work constraints that impose a significant burden to return to the clinic for a prescription visit
Those who report risk behaviors that put them at substantial risk of acquiring HIV infection in the time between visits for evaluation and PrEP prescription
Nondaily oral PrEP regimens (also called “2-1-1” or “on-demand” regimens) may be considered in men who have sex with men (MSM) who have infrequent sexual exposures, although this is not Food and Drug Administration (FDA)-approved.
Once PrEP is initiated, regular follow-up visits are required for follow-up testing and assessment; recommended frequency and nature of follow-up visits differs according to patient age as well as the type of PrEP prescribed.
Medication adherence is critical to achieving the maximum prevention benefit from PrEP.
Approaches that can effectively support medication adherence include:
Educating patients about their medications
Helping them anticipate and manage adverse effects
Asking about adherence successes and issues at follow-up visits
Helping them establish dosing routines that mesh with their work and social schedules
Providing reminder systems and tools
Addressing financial, substance use disorder, or mental health needs that may impede adherence
Facilitating social support
Goal
Prevent acquisition of HIV
The ultimate goal of PrEP is to prevent the acquisition of HIV infection with its resulting morbidity, mortality, and cost to individuals and society.
To achieve this goal, it is recommended that clinicians:
Prescribe medication regimens that are proven safe and effective
Educate patients about the medications and the regimen to maximize their safe use
Provide support for medication-adherence to help patients achieve and maintain protective levels of medication in their bodies
Provide HIV risk-reduction support and prevention services or service referrals to help patients minimize their exposure to HIV and other STIs
Provide (or refer for) effective contraception to persons with childbearing potential who are taking PrEP and who do not wish to become pregnant
Monitor patients to detect HIV infection, medication toxicities, and levels of risk behavior in order to make indicated changes in strategies to support patients’ long-term health
PrEP medication may be discontinued for several reasons, including:
Patient choice
Changed life situations resulting in lowered risk of HIV acquisition
Intolerable toxicities
Chronic nonadherence to the prescribed dosing regimen or scheduled follow-up care visits
Acquisition of HIV
Protection from HIV infection will wane over 7-10 days after ceasing daily oral PrEP use.
Cabotegravir levels slowly wane over many months after injections are discontinued. At some point during this “tail” phase, cabotegravir levels will fall below a protective threshold and persist for some time at nonprotective levels exposing the patient to the risk of HIV acquisition. These lower levels of cabotegravir may be sufficient to apply selective pressure that selects for viral strains with mutations that confer resistance to cabotegravir which may complicate future HIV treatment.
With HIV positive partner with undetectable viral load (<200 copies/mL for at least the prior 6 months)
Intervention
Prescribe PrEP if requested
Although people with HIV who have an undetectable viral load pose effectively no risk for HIV transmission to sexual partners, PrEP may be indicated if the partner without HIV seeking PrEP either has other sexual partners or wants the additional reassurance of protection that PrEP can provide.
Although not a direct indication for PrEP, people may request PrEP because of concern about acquiring HIV but not feel comfortable reporting sexual or injection behaviors to avoid anticipated stigmatizing responses in health care settings.
For this reason, after attempts to assess patient sexual and injection behaviors, it is recommended that clinicians offer PrEP to all patients who request it, even when no specific risk behaviors are elicited.
PrEP regimens include:
Daily oral PrEP with tenofovir/emtricitabine
Tenofovir disoproxil/emtricitabine is suitable for both men and women.
Tenofovir alafenamide/emtricitabine is recommended in men and transgender women only at increased sexual risk (it has not been studied in women as yet).
Long-acting injectable PrEP with intramuscular cabotegravir
Suitable for HIV prevention in adults at increased sexual risk.
Daily oral tenofovir disoproxil/emtricitabine is most commonly prescribed for PrEP.
However, of the oral options, oral tenofovir alafenamide/emtricitabine is the recommended option for patients with renal impairment; it is indicated in patients with an estimated creatinine clearance of <60 mL/min but ≥30 mL/min.
Clinicians may preferentially recommend oral tenofovir alafenamide/emtricitabine for persons with previously documented osteoporosis or related bone disease but routine screening for bone density is not recommended for PrEP patients.
Cabotegravir injections may be appropriate for patients with significant renal disease (use caution), those who have had difficulty with adherent use of oral PrEP and those who prefer injections every 2 months to an oral PrEP dosing schedule.
For select patients, consider same day prescription of PrEP, providing the clinic is able to meet certain safety requirements including availability of point-of-care HIV testing.
Same-day prescription may be a suitable approach for:
Those with time or work constraints that impose a significant burden to return to the clinic for a prescription visit
Those who report risk behaviors that put them at substantial risk of acquiring HIV infection in the time between visits for evaluation and PrEP prescription
Nondaily oral PrEP regimens (also called “2-1-1” or “on-demand” regimens) may be considered in MSM who have infrequent sexual exposures, although this is not FDA-approved.
Once PrEP is initiated, regular follow-up visits are required for follow-up testing and assessment; recommended frequency and nature of follow-up visits differs according to the type of prep prescribed.
Medication adherence is critical to achieving the maximum prevention benefit from PrEP.
Approaches that can effectively support medication adherence include:
Educating patients about their medications
Helping them anticipate and manage adverse effects
Asking about adherence successes and issues at follow-up visits
Helping them establish dosing routines that mesh with their work and social schedules
Providing reminder systems and tools
Addressing financial, substance use disorder, or mental health needs that may impede adherence
Facilitating social support
Goal
Prevent acquisition of HIV
The ultimate goal of PrEP is to prevent the acquisition of HIV infection with its resulting morbidity, mortality, and cost to individuals and society.
To achieve this goal, it is recommended that clinicians:
Prescribe medication regimens that are proven safe and effective
Educate patients about the medications and the regimen to maximize their safe use
Provide support for medication-adherence to help patients achieve and maintain protective levels of medication in their bodies
Provide HIV risk-reduction support and prevention services or service referrals to help patients minimize their exposure to HIV and other STIs
Provide (or refer for) effective contraception to persons with childbearing potential who are taking PrEP and who do not wish to become pregnant
Monitor patients to detect HIV infection, medication toxicities, and levels of risk behavior in order to make indicated changes in strategies to support patients’ long-term health
PrEP medication may be discontinued for several reasons, including:
Patient choice
Changed life situations resulting in lowered risk of HIV acquisition
Intolerable toxicities
Chronic nonadherence to the prescribed dosing regimen or scheduled follow-up care visits
Acquisition of HIV
Protection from HIV infection will wane over 7-10 days after ceasing daily oral PrEP use.
Cabotegravir levels slowly wane over many months after injections are discontinued. At some point during this “tail” phase, cabotegravir levels will fall below a protective threshold and persist for some time at nonprotective levels exposing the patient to the risk of HIV acquisition. These lower levels of cabotegravir may be sufficient to apply selective pressure that selects for viral strains with mutations that confer resistance to cabotegravir which may complicate future HIV treatment.
With one or more sex partner(s) of unknown HIV status (and does not always use a condom)
Intervention
Prescribe PrEP
Inconsistent condom use is not considered an effective method of preventing HIV transmission; therefore, unless the patient reports confidence that consistent condom use can be achieved (ie ‘always’ use of a condom), PrEP is recommended, in conjunction with support for condom use for prevention of STIs and unplanned pregnancy.
PrEP regimens include:
Daily oral PrEP with tenofovir/emtricitabine
Tenofovir disoproxil/emtricitabine is suitable for both men and women.
Tenofovir alafenamide/emtricitabine is recommended in men and transgender women only at increased sexual risk (it has not been studied in women as yet).
Long-acting injectable PrEP with intramuscular cabotegravir
Suitable for HIV prevention in adults at increased sexual risk.
Daily oral tenofovir disoproxil/emtricitabine is most commonly prescribed for PrEP.
However, of the oral options, oral tenofovir alafenamide/emtricitabine is the recommended option for patients with renal impairment; it is indicated in patients with an estimated creatinine clearance of <60 mL/min but ≥30 mL/min.
Clinicians may preferentially recommend oral tenofovir alafenamide/emtricitabine for persons with previously documented osteoporosis or related bone disease but routine screening for bone density is not recommended for PrEP patients.
Cabotegravir injections may be appropriate for patients with significant renal disease (use caution), those who have had difficulty with adherent use of oral PrEP and those who prefer injections every 2 months to an oral PrEP dosing schedule.
For select patients, consider same day prescription of PrEP, providing the clinic is able to meet certain safety requirements including availability of point-of-care HIV testing.
Same-day prescription may be a suitable approach for:
Those with time or work constraints that impose a significant burden to return to the clinic for a prescription visit
Those who report risk behaviors that put them at substantial risk of acquiring HIV infection in the time between visits for evaluation and PrEP prescription
Nondaily oral PrEP regimens (also called “2-1-1” or “on-demand” regimens) may be considered in MSM who have infrequent sexual exposures, although this is not FDA-approved.
Once PrEP is initiated, regular follow-up visits are required for follow-up testing and assessment; recommended frequency and nature of follow-up visits differs according to the type of prep prescribed.
Medication adherence is critical to achieving the maximum prevention benefit from PrEP.
Approaches that can effectively support medication adherence include:
Educating patients about their medications
Helping them anticipate and manage adverse effects
Asking about adherence successes and issues at follow-up visits
Helping them establish dosing routines that mesh with their work and social schedules
Providing reminder systems and tools
Addressing financial, substance use disorder, or mental health needs that may impede adherence
Facilitating social support
Offer HIV testing of partners when a patient reports that one or more regular sex partners is of unknown HIV status; this may take place either in the clinician’s practice or at a confidential testing site.
Goal
Prevent acquisition of HIV
The ultimate goal of PrEP is to prevent the acquisition of HIV infection with its resulting morbidity, mortality, and cost to individuals and society.
To achieve this goal, it is recommended that clinicians:
Prescribe medication regimens that are proven safe and effective
Educate patients about the medications and the regimen to maximize their safe use
Provide support for medication-adherence to help patients achieve and maintain protective levels of medication in their bodies
Provide HIV risk-reduction support and prevention services or service referrals to help patients minimize their exposure to HIV and other STIs
Provide (or refer for) effective contraception to persons with childbearing potential who are taking PrEP and who do not wish to become pregnant
Monitor patients to detect HIV infection, medication toxicities, and levels of risk behavior in order to make indicated changes in strategies to support patients’ long-term health
PrEP medication may be discontinued for several reasons, including:
Patient choice
Changed life situations resulting in lowered risk of HIV acquisition
Intolerable toxicities
Chronic nonadherence to the prescribed dosing regimen or scheduled follow-up care visits
Acquisition of HIV
Protection from HIV infection will wane over 7-10 days after ceasing daily oral PrEP use.
Cabotegravir levels slowly wane over many months after injections are discontinued. At some point during this “tail” phase, cabotegravir levels will fall below a protective threshold and persist for some time at nonprotective levels exposing the patient to the risk of HIV acquisition. These lower levels of cabotegravir may be sufficient to apply selective pressure that selects for viral strains with mutations that confer resistance to cabotegravir which may complicate future HIV treatment.
With one or more sex partner(s) of unknown HIV status (always uses a condom)
Intervention
Prescribe PrEP if requested
Reported consistent (“always”) condom use is associated with an 80% reduction in HIV acquisition among heterosexual couples and 70% among MSM.
Consider the epidemiologic context of the sexual practices reported by the patient. The risk of HIV acquisition is higher when there is an increased likelihood that a sex partner has HIV, e.g. when they are a member of a population with high HIV prevalence.
Although not a direct indication for PrEP, people may request PrEP because of concern about acquiring HIV but not feel comfortable reporting sexual or injection behaviors to avoid anticipated stigmatizing responses in health care settings.
For this reason, after attempts to assess patient sexual and injection behaviors, it is recommended that clinicians offer PrEP to all patients who request it, even when no specific risk behaviors are elicited.
PrEP regimens include:
Daily oral PrEP with tenofovir/emtricitabine
Tenofovir disoproxil/emtricitabine is suitable for both men and women.
Tenofovir alafenamide/emtricitabine is recommended in men and transgender women only at increased sexual risk (it has not been studied in women as yet).
Long-acting injectable PrEP with intramuscular cabotegravir
Suitable for HIV prevention in adults at increased sexual risk.
Daily oral tenofovir disoproxil/emtricitabine is most commonly prescribed for PrEP.
However, of the oral options, oral tenofovir alafenamide/emtricitabine is the recommended option for patients with renal impairment; it is indicated in patients with an estimated creatinine clearance of <60 mL/min but ≥30 mL/min.
Clinicians may preferentially recommend oral tenofovir alafenamide/emtricitabine for persons with previously documented osteoporosis or related bone disease but routine screening for bone density is not recommended for PrEP patients.
Cabotegravir injections may be appropriate for patients with significant renal disease (use caution), those who have had difficulty with adherent use of oral PrEP and those who prefer injections every 2 months to an oral PrEP dosing schedule.
For select patients, consider same day prescription of PrEP, providing the clinic is able to meet certain safety requirements including availability of point-of-care HIV testing.
Same-day prescription may be a suitable approach for:
Those with time or work constraints that impose a significant burden to return to the clinic for a prescription visit
Those who report risk behaviors that put them at substantial risk of acquiring HIV infection in the time between visits for evaluation and PrEP prescription
Nondaily oral PrEP regimens (also called “2-1-1” or “on-demand” regimens) may be considered in MSM who have infrequent sexual exposures, although this is not FDA-approved.
Once PrEP is initiated, regular follow-up visits are required for follow-up testing and assessment; recommended frequency and nature of follow-up visits differs according to the type of prep prescribed.
Medication adherence is critical to achieving the maximum prevention benefit from PrEP.
Approaches that can effectively support medication adherence include:
Educating patients about their medications
Helping them anticipate and manage adverse effects
Asking about adherence successes and issues at follow-up visits
Helping them establish dosing routines that mesh with their work and social schedules
Providing reminder systems and tools
Addressing financial, substance use disorder, or mental health needs that may impede adherence
Facilitating social support
Offer HIV testing of partners when a patient reports that one or more regular sex partners is of unknown HIV status; this may take place either in the clinician’s practice or at a confidential testing site.
Goal
Prevent acquisition of HIV
The ultimate goal of PrEP is to prevent the acquisition of HIV infection with its resulting morbidity, mortality, and cost to individuals and society.
To achieve this goal, it is recommended that clinicians:
Prescribe medication regimens that are proven safe and effective
Educate patients about the medications and the regimen to maximize their safe use
Provide support for medication-adherence to help patients achieve and maintain protective levels of medication in their bodies
Provide HIV risk-reduction support and prevention services or service referrals to help patients minimize their exposure to HIV and other STIs
Provide (or refer for) effective contraception to persons with childbearing potential who are taking PrEP and who do not wish to become pregnant
Monitor patients to detect HIV infection, medication toxicities, and levels of risk behavior in order to make indicated changes in strategies to support patients’ long-term health
PrEP medication may be discontinued for several reasons, including:
Patient choice
Changed life situations resulting in lowered risk of HIV acquisition
Intolerable toxicities
Chronic nonadherence to the prescribed dosing regimen or scheduled follow-up care visits
Acquisition of HIV
Protection from HIV infection will wane over 7-10 days after ceasing daily oral PrEP use.
Cabotegravir levels slowly wane over many months after injections are discontinued. At some point during this “tail” phase, cabotegravir levels will fall below a protective threshold and persist for some time at nonprotective levels exposing the patient to the risk of HIV acquisition. These lower levels of cabotegravir may be sufficient to apply selective pressure that selects for viral strains with mutations that confer resistance to cabotegravir which may complicate future HIV treatment.
With diagnosis of gonorrhea, chlamydia or syphilis in the past 6 months
Intervention
Prescribe PrEP
Ask all sexually-active patients about any diagnoses of bacterial STIs during the past 6 months, because they provide evidence of sexual activity that could result in HIV exposure.
PrEP is indicated for all those who have been diagnosed with gonorrhea, chlamydia or syphilis in the past 6 months.
PrEP regimens include:
Daily oral PrEP with tenofovir/emtricitabine
Tenofovir disoproxil/emtricitabine is suitable for both men and women.
Tenofovir alafenamide/emtricitabine is recommended in men and transgender women only at increased sexual risk (it has not been studied in women as yet).
Long-acting injectable PrEP with intramuscular cabotegravir
Suitable for HIV prevention in adults at increased sexual risk.
Daily oral tenofovir disoproxil/emtricitabine is most commonly prescribed for PrEP.
However, of the oral options, oral tenofovir alafenamide/emtricitabine is the recommended option for patients with renal impairment; it is indicated in patients with an estimated creatinine clearance of <60 mL/min but ≥30 mL/min.
Clinicians may preferentially recommend oral tenofovir alafenamide/emtricitabine for persons with previously documented osteoporosis or related bone disease but routine screening for bone density is not recommended for PrEP patients.
Cabotegravir injections may be appropriate for patients with significant renal disease (use caution), those who have had difficulty with adherent use of oral PrEP and those who prefer injections every 2 months to an oral PrEP dosing schedule.
For select patients, consider same day prescription of PrEP, providing the clinic is able to meet certain safety requirements including availability of point-of-care HIV testing.
Same-day prescription may be a suitable approach for:
Those with time or work constraints that impose a significant burden to return to the clinic for a prescription visit
Those who report risk behaviors that put them at substantial risk of acquiring HIV infection in the time between visits for evaluation and PrEP prescription
Nondaily oral PrEP regimens (also called “2-1-1” or “on-demand” regimens) may be considered in MSM who have infrequent sexual exposures, although this is not FDA-approved.
Once PrEP is initiated, regular follow-up visits are required for follow-up testing and assessment; recommended frequency and nature of follow-up visits differs according to the type of prep prescribed.
Medication adherence is critical to achieving the maximum prevention benefit from PrEP.
Approaches that can effectively support medication adherence include:
Educating patients about their medications
Helping them anticipate and manage adverse effects
Asking about adherence successes and issues at follow-up visits
Helping them establish dosing routines that mesh with their work and social schedules
Providing reminder systems and tools
Addressing financial, substance use disorder, or mental health needs that may impede adherence
Facilitating social support
Goal
Prevent acquisition of HIV
The ultimate goal of PrEP is to prevent the acquisition of HIV infection with its resulting morbidity, mortality, and cost to individuals and society.
To achieve this goal, it is recommended that clinicians:
Prescribe medication regimens that are proven safe and effective
Educate patients about the medications and the regimen to maximize their safe use
Provide support for medication-adherence to help patients achieve and maintain protective levels of medication in their bodies
Provide HIV risk-reduction support and prevention services or service referrals to help patients minimize their exposure to HIV and other STIs
Provide (or refer for) effective contraception to persons with childbearing potential who are taking PrEP and who do not wish to become pregnant
Monitor patients to detect HIV infection, medication toxicities, and levels of risk behavior in order to make indicated changes in strategies to support patients’ long-term health
PrEP medication may be discontinued for several reasons, including:
Patient choice
Changed life situations resulting in lowered risk of HIV acquisition
Intolerable toxicities
Chronic nonadherence to the prescribed dosing regimen or scheduled follow-up care visits
Acquisition of HIV
Protection from HIV infection will wane over 7-10 days after ceasing daily oral PrEP use.
Cabotegravir levels slowly wane over many months after injections are discontinued. At some point during this “tail” phase, cabotegravir levels will fall below a protective threshold and persist for some time at nonprotective levels exposing the patient to the risk of HIV acquisition. These lower levels of cabotegravir may be sufficient to apply selective pressure that selects for viral strains with mutations that confer resistance to cabotegravir which may complicate future HIV treatment.
With bacterial STI in the past 6 months (excluding gonorrhea, chlamydia or syphilis)
Intervention
Prescribe PrEP if requested
Ask all sexually-active patients about any diagnoses of bacterial STIs during the past 6 months, because they provide evidence of sexual activity that could result in HIV exposure.
Consider the epidemiologic context of the sexual practices reported by the patient. The risk of HIV acquisition is higher when there is an increased likelihood that a sex partner has HIV, for example when they are a member of a population with high HIV prevalence.
Although not a direct indication for PrEP, people may request PrEP because of concern about acquiring HIV but not feel comfortable reporting sexual or injection behaviors to avoid anticipated stigmatizing responses in health care settings.
For this reason, after attempts to assess patient sexual and injection behaviors, it is recommended that clinicians offer PrEP to all patients who request it, even when no specific risk behaviors are elicited.PrEP regimens include:
Daily oral PrEP with tenofovir/emtricitabine
Tenofovir disoproxil/emtricitabine is suitable for both men and women.
Tenofovir alafenamide/emtricitabine is recommended in men and transgender women only at increased sexual risk (it has not been studied in women as yet).
Long-acting injectable PrEP with intramuscular cabotegravir
Suitable for HIV prevention in adults at increased sexual risk.
Daily oral tenofovir disoproxil/emtricitabine is most commonly prescribed for PrEP.
However, of the oral options, oral tenofovir alafenamide/emtricitabine is the recommended option for patients with renal impairment; it is indicated in patients with an estimated creatinine clearance of <60 mL/min but ≥30 mL/min.
Clinicians may preferentially recommend oral tenofovir alafenamide/emtricitabine for persons with previously documented osteoporosis or related bone disease but routine screening for bone density is not recommended for PrEP patients.
Cabotegravir injections may be appropriate for patients with significant renal disease (use caution), those who have had difficulty with adherent use of oral PrEP and those who prefer injections every 2 months to an oral PrEP dosing schedule.
For select patients, consider same day prescription of PrEP, providing the clinic is able to meet certain safety requirements including availability of point-of-care HIV testing.
Same-day prescription may be a suitable approach for:
Those with time or work constraints that impose a significant burden to return to the clinic for a prescription visit
Those who report risk behaviors that put them at substantial risk of acquiring HIV infection in the time between visits for evaluation and PrEP prescription
Nondaily oral PrEP regimens (also called “2-1-1” or “on-demand” regimens)(on-demand) PrEP may be considered in MSM who have infrequent sexual exposures, although this is not Food and Drug Administration (FDA)-approved.
Once PrEP is initiated, regular follow-up visits are required for follow-up testing and assessment; recommended frequency and nature of follow-up visits differs according to the type of prep prescribed.
Medication adherence is critical to achieving the maximum prevention benefit from PrEP.
Approaches that can effectively support medication adherence include:
Educating patients about their medications
Helping them anticipate and manage adverse effects
Asking about adherence successes and issues at follow-up visits
Helping them establish dosing routines that mesh with their work and social schedules
Providing reminder systems and tools
Addressing financial, substance use disorder, or mental health needs that may impede adherence
Facilitating social support
Goal
Prevent acquisition of HIV
The ultimate goal of PrEP is to prevent the acquisition of HIV infection with its resulting morbidity, mortality, and cost to individuals and society.
To achieve this goal, it is recommended that clinicians:
Prescribe medication regimens that are proven safe and effective
Educate patients about the medications and the regimen to maximize their safe use
Provide support for medication-adherence to help patients achieve and maintain protective levels of medication in their bodies
Provide HIV risk-reduction support and prevention services or service referrals to help patients minimize their exposure to HIV and other STIs
Provide (or refer for) effective contraception to persons with childbearing potential who are taking PrEP and who do not wish to become pregnant
Monitor patients to detect HIV infection, medication toxicities, and levels of risk behavior in order to make indicated changes in strategies to support patients’ long-term health
PrEP medication may be discontinued for several reasons, including:
Patient choice
Changed life situations resulting in lowered risk of HIV acquisition
Intolerable toxicities
Chronic nonadherence to the prescribed dosing regimen or scheduled follow-up care visits
Acquisition of HIV
Protection from HIV infection will wane over 7-10 days after ceasing daily oral PrEP use.
Cabotegravir levels slowly wane over many months after injections are discontinued. At some point during this “tail” phase, cabotegravir levels will fall below a protective threshold and persist for some time at nonprotective levels exposing the patient to the risk of HIV acquisition. These lower levels of cabotegravir may be sufficient to apply selective pressure that selects for viral strains with mutations that confer resistance to cabotegravir which may complicate future HIV treatment.
Adult without HIV and not currently taking PrEP; history of injection drug use
Possible acute HIV infection must be ruled out on history, examination and laboratory tests for all patients in whom PrEP is being considered. Renal function must also be assessed before starting PrEP medication as it may affect choice of drug/dose.
All
Intervention
Consider referral for treatment or harm-reduction services for substance use disorder; consider PrEP following an HIV risk assessment
If a substance use disorder is identified, provide referral for appropriate services acceptable to the patient.
This may include referral for:
Treatment of substance use disorder
Mental health services
Harm reduction programs
Syringe service programs (SSPs) where available or access to sterile injection equipment
Social services
For people with a history of injecting illicit drugs but who are currently not injecting, consider the risk of relapse along with the patients’ use of relapse prevention services (e.g., a drug-related behavioral support program, use of mental health services, medication-assisted therapy,12-step program).
Because most people who use intravenous drugs are sexually active, and many acquire HIV from sexual exposures, assess people for both sexual and injection behaviors that indicate HIV risk.
Note that people may request PrEP because of concern about acquiring HIV but not feel comfortable reporting sexual or injection behaviors to avoid anticipated stigmatizing responses in health care settings.
For this reason, after attempts to assess patient sexual and injection behaviors, it is recommended that clinicians offer PrEP to all patients who request it, even when no specific risk behaviors are elicited.
It is recommended that PrEP and other HIV prevention should be provided and integrated with prevention and clinical care services for other non-HIV health threats (e.g., hepatitis B and C infection, abscesses, septicemia, endocarditis, overdose).
Goal
To reduce substance use-associated risk; facilitate risk assessment to guide PrEP; prevent acquisition of HIV in those at increased risk
With injection drug use in the past 6 months; reports use of shared injection equipment
Intervention
Prescribe PrEP
Use of shared injection equipment within the past 6 months is an indication for PrEP. Injection practices resulting in shared use include persons who inject drugs, transgender people administering non-prescribed gender-affirming hormones, or persons injecting silicone or other fillers to alter body shape.
PrEP regimens include:
Daily oral PrEP with tenofovir/emtricitabine
Tenofovir disoproxil/emtricitabine is suitable for both men and women.
Tenofovir alafenamide/emtricitabine is recommended in men and transgender women only at increased sexual risk (it has not been studied in women as yet).
Long-acting injectable PrEP with intramuscular cabotegravir
Suitable for HIV prevention in adults at increased sexual risk.
Although most people who use intravenous drugs are sexually active, and many acquire HIV from sexual exposures, people who use intravenous drugs are likely to benefit from PrEP with any Food and Drug Administration (FDA)-approved medication with or without an identified sexual behavior risk of HIV acquisition.
Daily oral tenofovir disoproxil/emtricitabine is most commonly prescribed for PrEP.
However, of the oral options, oral tenofovir alafenamide/emtricitabine is the recommended option for patients with renal impairment; it is indicated in patients with an estimated creatinine clearance of <60 mL/min but ≥30 mL/min.
Clinicians may preferentially recommend oral tenofovir alafenamide/emtricitabine for persons with previously documented osteoporosis or related bone disease but routine screening for bone density is not recommended for PrEP patients.
Cabotegravir injections may be appropriate for patients with significant renal disease (use caution), those who have had difficulty with adherent use of oral PrEP and those who prefer injections every 2 months to an oral PrEP dosing schedule.
For select patients, consider same day prescription of PrEP, providing the clinic is able to meet certain safety requirements including availability of point-of-care HIV testing. Same-day prescription may be a suitable approach for:
Those with time or work constraints that impose a significant burden to return to the clinic for a prescription visit
Those who report risk behaviors that put them at substantial risk of acquiring HIV infection in the time between visits for evaluation and PrEP prescription
Once PrEP is initiated, regular follow-up visits are required for follow-up testing and assessment; recommended frequency and nature of follow-up visits differs according to patient age as well as the type of PrEP prescribed.
Medication adherence is critical to achieving the maximum prevention benefit from PrEP.
Approaches that can effectively support medication adherence include:
Educating patients about their medications
Helping them anticipate and manage adverse effects
Asking about adherence successes and issues at follow-up visits
Helping them establish dosing routines that mesh with their work and social schedules
Providing reminder systems and tools
Addressing financial, substance use disorder, or mental health needs that may impede adherence
Facilitating social support
Goal
Prevent acquisition of HIV
The ultimate goal of PrEP is to prevent the acquisition of HIV infection with its resulting morbidity, mortality, and cost to individuals and society.
To achieve this goal, it is recommended that clinicians:
Prescribe medication regimens that are proven safe and effective
Educate patients about the medications and the regimen to maximize their safe use
Provide support for medication-adherence to help patients achieve and maintain protective levels of medication in their bodies
Provide HIV risk-reduction support and prevention services or service referrals to help patients minimize their exposure to HIV and other STIs
Provide (or refer for) effective contraception to persons with childbearing potential who are taking PrEP and who do not wish to become pregnant
Monitor patients to detect HIV infection, medication toxicities, and levels of risk behavior in order to make indicated changes in strategies to support patients’ long-term health
PrEP medication may be discontinued for several reasons, including:
Patient choice
Changed life situations resulting in lowered risk of HIV acquisition
Intolerable toxicities
Chronic nonadherence to the prescribed dosing regimen or scheduled follow-up care visits
Acquisition of HIV
Protection from HIV infection will wane over 7-10 days after ceasing daily oral PrEP use.
Cabotegravir levels slowly wane over many months after injections are discontinued. At some point during this “tail” phase, cabotegravir levels will fall below a protective threshold and persist for some time at nonprotective levels exposing the patient to the risk of HIV acquisition. These lower levels of cabotegravir may be sufficient to apply selective pressure that selects for viral strains with mutations that confer resistance to cabotegravir which may complicate future HIV treatment.
With injection drug use without shared equipment in the past 6 months, or with injection drug use (whether or not equipment was shared) more than 6 months ago
Intervention
Prescribe PrEP if requested
Although not a direct indication for PrEP, people may request PrEP because of concern about acquiring HIV but not feel comfortable reporting sexual or injection behaviors to avoid anticipated stigmatizing responses in health care settings.
For this reason, after attempts to assess patient sexual and injection behaviors, it is recommended that clinicians offer PrEP to all patients who request it, even when no specific risk behaviors are elicited.
PrEP regimens include:
Daily oral PrEP with tenofovir/emtricitabine
Tenofovir disoproxil/emtricitabine is suitable for both men and women.
Tenofovir alafenamide/emtricitabine is recommended in men and transgender women only at increased sexual risk (it has not been studied in women as yet).
Long-acting injectable PrEP with intramuscular cabotegravir
Suitable for HIV prevention in adults at increased sexual risk.
Although most people who use intravenous drugs are sexually active, and many acquire HIV from sexual exposures, people who use intravenous drugs are likely to benefit from PrEP with any Food and Drug Administration (FDA)-approved medication with or without an identified sexual behavior risk of HIV acquisition.
Daily oral tenofovir disoproxil/emtricitabine is most commonly prescribed for PrEP.
However, of the oral options, oral tenofovir alafenamide/emtricitabine is the recommended option for patients with renal impairment; it is indicated in patients with an estimated creatinine clearance of <60 mL/min but ≥30 mL/min.
Clinicians may preferentially recommend oral tenofovir alafenamide/emtricitabine for persons with previously documented osteoporosis or related bone disease but routine screening for bone density is not recommended for PrEP patients.
Cabotegravir injections may be appropriate for patients with significant renal disease (use caution), those who have had difficulty with adherent use of oral PrEP and those who prefer injections every 2 months to an oral PrEP dosing schedule.
For select patients, consider same day prescription of PrEP, providing the clinic is able to meet certain safety requirements including availability of point-of-care HIV testing.
Same-day prescription may be a suitable approach for:
Those with time or work constraints that impose a significant burden to return to the clinic for a prescription visit
Those who report risk behaviors that put them at substantial risk of acquiring HIV infection in the time between visits for evaluation and PrEP prescription
Once PrEP is initiated, regular follow-up visits are required for follow-up testing and assessment; recommended frequency and nature of follow-up visits differs according to the type of prep prescribed.
Medication adherence is critical to achieving the maximum prevention benefit from PrEP.
Approaches that can effectively support medication adherence include:
Educating patients about their medications
Helping them anticipate and manage adverse effects
Asking about adherence successes and issues at follow-up visits
Helping them establish dosing routines that mesh with their work and social schedules
Providing reminder systems and tools
Addressing financial, substance use disorder, or mental health needs that may impede adherence
Facilitating social support
Goal
Prevent acquisition of HIV
The ultimate goal of PrEP is to prevent the acquisition of HIV infection with its resulting morbidity, mortality, and cost to individuals and society.
To achieve this goal, it is recommended that clinicians:
Prescribe medication regimens that are proven safe and effective
Educate patients about the medications and the regimen to maximize their safe use
Provide support for medication-adherence to help patients achieve and maintain protective levels of medication in their bodies
Provide HIV risk-reduction support and prevention services or service referrals to help patients minimize their exposure to HIV and other STIs
Provide (or refer for) effective contraception to persons with childbearing potential who are taking PrEP and who do not wish to become pregnant
Monitor patients to detect HIV infection, medication toxicities, and levels of risk behavior in order to make indicated changes in strategies to support patients’ long-term health
PrEP medication may be discontinued for several reasons, including:
Patient choice
Changed life situations resulting in lowered risk of HIV acquisition
Intolerable toxicities
Chronic nonadherence to the prescribed dosing regimen or scheduled follow-up care visits
Acquisition of HIV
Protection from HIV infection will wane over 7-10 days after ceasing daily oral PrEP use.
Cabotegravir levels slowly wane over many months after injections are discontinued. At some point during this “tail” phase, cabotegravir levels will fall below a protective threshold and persist for some time at nonprotective levels exposing the patient to the risk of HIV acquisition. These lower levels of cabotegravir may be sufficient to apply selective pressure that selects for viral strains with mutations that confer resistance to cabotegravir which may complicate future HIV treatment.
Adult without HIV; not receiving PrEP or not fully adhering to PrEP; with non-occupational HIV exposure
All
Intervention
Consider nonoccupational HIV post-exposure prophylaxis (PEP)
For patients not receiving PrEP who seek care within 72 hours after an isolated sexual or injection related HIV exposure, evaluate for the potential need for PEP.
If the exposure is isolated (e.g., sexual assault, infrequent condom failure), prescribe PEP, but PrEP or other continued antiretroviral medication is not indicated after completion of the 28-day PEP course.
Patients fully adhering to a daily PrEP regimen or who have received cabotegravir injections on schedule do not need PEP if they experience a potential HIV exposure while on PrEP.
For patients who report taking their PrEP medication sporadically, and those who did not take it within the week before the recent exposure, initiating a 28-day course of PEP might be indicated.
For patients not currently receiving PrEP who seek one or more courses of PEP and who are at risk for ongoing HIV exposures, evaluate for possible PrEP use after confirming they have not acquired HIV.
Goal
Prevent acquisition of HIV
The goal is to prevent the acquisition of HIV infection with its resulting morbidity, mortality, and cost to individuals and society.
Secondary prevention
Sexual contacts
Sexual contacts of the patient should be inquired about. HIV status may already be known. If not, disclosure should be discussed. Patients may not be able to do this immediately but should be encouraged, especially in a situation where disclosure is linked to being able to practice safer sex. Practitioners may also offer to assist with disclosure under these circumstances and offer immediate testing for partners. There may be local regulations, and physicians should refer to these where appropriate. Public health officers may be able to facilitate partner notification.
Serodiscordant partners should be encouraged to be tested regularly, and can be protected from HIV by immediate initiation of antiretroviral therapy (ART) in the HIV-positive partner.[70][71][78][231] [
]
Offspring
The physician should inquire whether the patient has children and how old they are. Their well-being and medical histories may give a clue to possible infection (if not already tested). If younger than 10 years of age and well and not previously tested, the physician may also advise having them tested. Children younger than 18 months of age may need a nucleic acid test (qualitative polymerase chain reaction). If still breast-feeding, advice against ongoing transmission risk should be given and consideration to weaning (if older than 6 months of age) or switching to bottle/formula feeding.[232]
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