PrEP: Simple and Effective Yet Underused in HIV prevention.

Pre-Exposure Prophylaxis (PrEP), an important way for clinicians to protect their patients from becoming infected with HIV.
PrEP involves an HIV-negative person taking a pill containing tenofovir and emtricitabine. PrEP is taken daily and reduces sexual acquisition of HIV by more than 90% when taken correctly. Clinicians are key to increasing awareness of PrEP, and you can discuss HIV risk with all patients to better identify those who would benefit.
Every year, about 45,000 people in the United States are diagnosed with HIV. PrEP complements other tools to prevent HIV, such as condom use, HIV testing, and early diagnosis and treatment of HIV infection.
Any prescribing healthcare provider can deliver PrEP care. You have the power to protect your patients from HIV by assessing their risk from sex and drug use behaviors and offering PrEP to patients with the recommended indications.
CDC estimates that 1.2 million people in the United States may have indications for PrEP use, and these people fall into three groups^[1]:

• About 1 in 4 HIV-negative sexually active gay and bisexual adult men. This includes men who have multiple sex partners and report any anal sex without a condom or who had a recent sexually transmitted infection, as well as men who have an ongoing sexual relationship with an HIV-positive partner.
• About 1 in 5 HIV-negative adults who inject drugs. This includes people who share needles or equipment to inject drugs or have recently been in a drug treatment program.
• About 1 in 200 sexually active, HIV-negative heterosexual adults. This includes adults in an ongoing sexual relationship with HIV-positive partners. It also includes people who have multiple sex partners and who infrequently use condoms during sex with partners known to be at substantial risk for HIV infection. Partners at substantial risk include people who inject drugs and, for women, bisexual men.

Integrating the delivery of PrEP care into your practice involves five key steps:

• Test all adolescent and adult patients for HIV as recommended by the US Preventive Services Task Force and CDC as a routine part of medical care. Patients who test positive for HIV should be prescribed HIV treatment right away.
• Discuss HIV risks and prevention methods with all patients. If an HIV-negative patient has indications for PrEP and is interested in taking it, then move on to the next step.
• Perform the recommended laboratory tests, including tests to exclude acute HIV infection if the symptom history suggests this, and tests for renal function and hepatitis B virus. If the tests show that the patient is still a candidate for PrEP, then move on to the next step.
• Prescribe PrEP to your patient and counsel them about steps that they can take to make sure that PrEP is taken every day. If payment is an issue, provide assistance as to how they may apply for insurance or other programs.
• The last step is to schedule appointments every 3 months for follow-up including HIV testing and prescription refills.

Incorporating PrEP into your practice is simple, and it works. Since CDC published the Public Health Service Clinical Practice Guidelines for PrEP in 2014, open-label studies and demonstration projects conducted with gay and bisexual men in the United States achieved high adherence with PrEP.^[2-6] And a recent study conducted in New York State suggests that the use of PrEP as a prevention tool can be increased substantially for persons who are Medicaid-insured—if education efforts about PrEP for both clinicians and patients are implemented successfully.^[7]In closing, increasing the use of PrEP by patients could be a major tool in reducing the number of new HIV infections in the United States. But many clinicians who can prescribe PrEP, and many people who can benefit from it, aren't aware of it. Together we can scale up the use of this important HIV prevention tool.