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The Fundamentals of Selecting Individualized HIV PrEP Regimens
  • CME
  • CE

Gregory Huhn, MD, MPHTM
Released: August 12, 2022

PrEP Monitoring

HIV Monitoring on PrEP

The CDC PrEP guidelines, revised in late 2021, recommend use of HIV-1 RNA qualitative or quantitative assays for monitoring patients receiving oral or LA injectable PrEP.4 This approach is designed to reduce the risk of delayed recognition of breakthrough HIV infections. In the HPTN 083 study, there was a delay in diagnosis of incident infections using antigen and antibody testing compared with qualitative HIV-1 RNA testing.35 Detection of incident infections was delayed by a median of 98 days among individuals receiving CAB and 31 days among individuals receiving FTC/TDF.

This delay risks the development of drug resistance in individuals who acquire HIV infection and continue to receive their PrEP medication because PrEP regimens are insufficient to fully suppress HIV replication once an infection has occurred. In HPTN 083, 5 participants who received LA CAB after acquiring HIV infection developed integrase resistance.35 There were no similar cases in HPTN 084.28

It is recommended that people receiving PrEP be tested for HIV infection every 2 months if receiving CAB and every 3 months if receiving oral PrEP.4

Clinical Monitoring Parameters at Initiation and During PrEP

All patients receiving PrEP should be monitored with HIV antibody/antigen screening and HIV-1 RNA testing.4 Testing for sexually transmitted infections (STIs) also should be conducted at least every 3 months in all sexually active PrEP users with signs or symptoms of an STI and in asymptomatic MSM at high risk of STIs. In MSM, pharyngeal, rectal, and urine samples should be collected. Vaginal specimens are preferred for gonorrhea testing in cisgender women, and rectal specimens should be obtained for women who report anal sex.

Hepatitis B serology is required at baseline for patients receiving FTC/TDF or FTC/TAF because these antiviral agents are active against hepatitis B. Hepatitis C serology should be assessed at baseline and annually thereafter in MSM, TGW, and PWID.

Renal function should be assessed at baseline and every 6 or 12 months thereafter, depending on age and baseline CrCl. A lipid panel is required at baseline and every 12 months for those receiving FTC/TAF.

All PrEP users should receive counseling and support on adherence and HIV risk reduction at baseline and at least every 3 months while they are receiving treatment. Individuals who no longer feel that they are at risk and wish to stop treatment should be given the option to restart PrEP if their behavior changes.

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