In the implementation of its plan to update French recommendations for the care of people living with HIV, the High Authority for Health (HAS) has published a good practice recommendation about PrEP (pre-exposure prophylaxispre-exposure prophylaxis). PrEP is a preventive treatment for HIV infection that any doctor can prescribe as part of a doctor/nurse or doctor/midwife protocol. It is recommended for anyone at high risk of exposure to HIV.
First-line treatment
This involves the oral administration of the combination tenofovir disoproxil fumarate/emtricitabine (TDF/FTC).
- The two contraindications are the presence of HIV infection or renal failure with a glomerular filtration rate (GFR) 2. Pregnancy, breastfeeding and hormonal contraception are not contraindications.
- There are two prescription methods:
- In continuous form with two tablets during the first dose, then one tablet per day.
- In discontinuous form only in cisgender men or transgender people having exclusively anal intercourse (and excluding chronic hepatitis B virus-HBV infection): two tablets at least 2 hours before potential exposure, then one tablet per day until 48 hours after the last exposure.
Second-line treatment
This treatment requires administration by intramuscular injection of long-acting cabotegravir (CAB-LP). There is first a loading dose with two injections (one month apart) and then an injection every two months. It is reserved for cases where TDF/FTC treatment is contraindicated or there are difficulties in using it.
The initial consultation
This allows us to check for the absence of contraindications, to detect the possible existence of other sexually transmitted infections (STIs) in progress and offers a sexual health assessment.
The initial biological assessment
This assessment systematically includes HIV serology, GFR assessment and alanine aminotransferase (ALAT) level. Depending on previous laboratory results, vaccination history and type of exposure, it may be supplemented by HBV (hepatitis B), HCV (hepatitis C), HAV (hepatitis A), syphilis serology, a gonococcal PCR and Chlamydia trachomatis and/or a ß-hCG assay in women in the absence of contraception.
A follow-up consultation
It is performed one month after the initiation of PrEP, then regularly every two to six months depending on the patient’s needs. For PrEP by CAB-LP, systematic monitoring with HIV viral load is proposed in the first month, then every 2 months until the 5th injection, and finally every 4 months thereafter.
In case of stopping PrEP with TDF/FTC
If PrEP with TDF/FTC is stopped, the patient must take one TDF/FTC tablet per day for 2 days after the last sexual intercourse for cisgender men and transgender people who have anal intercourse, and one TDF/FTC tablet per day for 7 days for other populations. Any possible resumption of PrEP is carried out according to the same procedures as for the first prescription.
In case of stopping PrEP by CAB-LP
In case of stopping PrEP with CAB-LP, it is advisable to put in place another method of preventing HIV infection (relay with oral PrEP by TDF/FTC in the absence of contraindication or condoms) due to the very long half-life of CAB-LP (which can be detected up to 12 months after stopping) and the risk of selection of a virus resistant to integrase inhibitors in the event of intercurrent infection.
TDF/FTC Prescribing PrEP to Minors
PrEP by TDF/FTC can be prescribed to minors aged 12 or over. Confidentiality with respect to parents is best ensured in CeGIDD (Free information, screening and diagnostic centres for human immunodeficiency virus infections, viral hepatitis and sexually transmitted infections, no billing). It is necessary to ensure that the minor is not subjected to sexual violence.
In case of HBV carriage
For individuals carrying HBV (Hepatitis B Virus), specialist advice is necessary before stopping PrEP, with monitoring of transaminases. The patient must be informed of the risk of severe acute hepatitis.
