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doc10877 PrEP-guide-UK-Feb-2024-FIN-artifacted.pdf
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"text": "Changes to this edition 3\nGetting PrEP in the UK 3\nWhat is PrEP: first questions 4\nPrEP for women 8\nPrEP for trans and non-binary people 10\nPrEP and sex work 11\nBuying PrEP in the UK, including online 11\nBefore you start PrEP 13\nCare if you have already started PrEP 14\nHow to start and stop oral PrEP 15\nDaily PrEP 16\nEvent-based PrEP 17\nEvent-based 2:1:1 dosing: sex once 18\nEvent-based 2:1:1 dosing: more sex 19\nEvent-based 2:7 dosing 20\nOther tips on how to take PrEP 21\nCredits and further information 24",
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"text": "Written by Dan Clutterbuck, Simon Collins, Sheena McCormack, Achyuta Nori, Will Nutland, Greg Owen, Mags Portman[p2.4.1], Michelle Ross, Sophie Strachan, Martina Toby, Laura Waters, Ashwin Caffery and Aedan Wolton. Cover graphic: iwantPrEPnow.co.uk.",
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"text": "[p2.5.1]This guide is dedicated to our inspirational co-author Dr Mags Portman who was a leading advocate for PrEP in the UK. Mags died from mesothelioma in February 2019 aged 44 and we miss her deeply.",
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"text": "Thanks to the Chelsea and Westminster NHS Trust for help with printing."
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"text": "ISSN 2398-6409 (i-Base, London, 10th edition, February 2024)."
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Page 5
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"text": "These rare cases are usually because HIV was missed in the pre-test. Recent HIV infections (six weeks before the HIV test) are not always detected. This is why it is good to have another HIV test six weeks after either the most recent risk or after starting PrEP."
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"text": "Changes in bone structure are usually small and reverse after stopping TD/FTC. This is similar to a commonly used oral contraceptive but might be important if you are younger than 18 when bones are still developing. Bone strength was not fully reversed after a year in one study in adolescents aged 15 to 19."
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"text": "Starting PrEP without knowing that you are already HIV positive. This is why the HIV test before PrEP is essential. It is also why some people need to re-test after six weeks.",
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Page 7
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"text": "The HPV vaccine reduces the risk of genital warts and cervical and anal cancers. Please ask your clinic or GP about this. Your clinic should also provide vaccines for hepatitis A and B if needed, and for mpox."
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"text": "If you have sex for money, or receive gifts for sex.",
"marker": "•"
},
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"text": "If your partner or partners might be at risk of HIV. For example, if your partner has other partners. Or if you or your partner(s) inject drugs and share injecting equipment.",
"marker": "-"
}
]
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"text": "Please see p15 to 20 for ways women take PrEP.",
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"text": "This includes a new option to start with a double dose for rapid protection, and new information on daily, 2:1:1 and 2:7 dosing."
},
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Page 9
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Page 9 JSON
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"text": "If planning a pregnancy and not using barrier protection or condoms, daily PrEP can protect you from HIV."
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"text": "But if you know that your partner is HIV positive, it is better for them to be on HIV treatment. If their viral load is undetectable, this will also protect you from HIV."
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"text": "If you become pregnant while taking PrEP, continuing PrEP is still recommended but please also talk to your doctor."
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"text": "Outside the UK, many people living with HIV use the same meds as HIV treatment during breast and chest feeding."
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"text": "Only very small amounts of FTC and TD are present in breast milk. These low levels are not harmful to your baby."
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Page 10
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"text": "Dosing choices depend on the type of sex, although daily dosing has generally been recommended."
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"text": "Anyone having receptive vaginal/frontal sex can quick-start with a double dose (two pills). This works in two hours rather than the old advice to take daily PrEP for 7 days before sex."
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"text": "After sex, take daily PrEP (one pill) for seven days. For daily PrEP, current guidelines recommend at least six daily doses a week. This might be reduced in the 2024 UK guidelines."
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"text": "Anyone having insertive or receptive anal sex or insertive vaginal/frontal sex can use 2:1:1 event-based dosing. Event-based dosing using 2:7 dosing is recommended for receptive vaginal/frontal sex. Please see p15 to 20."
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"text": "PrEP is very safe with hormone treatment. Even though you might worry about drug interactions, neither your hormone or PrEP levels will be affected. Liverpool University produce an excellent guide to drug interactions between hormone treatments and other HIV meds:"
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"text": "www.hiv-druginteractions.org/printable_charts"
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"text": "Ongoing studies are looking at other aspects of PrEP in trans women and men."
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"text": "CliniQ (cliniq.org.uk) is a London-based specialist clinic providing sexual health and well-being services for trans people. The 56T clinic (dean.st/trans-non-binary) at 56 Dean Street in London also has PrEP services."
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"text": "Other trans clinics include Clinic T in Brighton (https://brightonsexualhealth.com/service/clinic-t) and Indigo Gender Service in Manchester (www.indigogenderservice.uk)."
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Page 11
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"text": "PrEP can be used for any job in the sex industry including porn."
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"text": "Many sex workers look after their sexual health but their clients might not. PrEP will protect against HIV if you are pressured to not use condoms. Use specialised services that are free from stigma and judgement. See: www.uglymugs.org"
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"text": "It is perfectly legal to buy PrEP online, if this is for personal use. Personal use is defined as up to three months of daily PrEP."
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"text": "Prices for online TD/FTC range from about £20 to £40 + post for 30 tablets. TAF/FTC is similar or a little more expensive."
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"text": "Generic PrEP contains the same meds as brand products but is made by different companies. For example, TD/FTC from NHS clinics will always be generic."
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"text": "This FDA listing includes approved versions to check if you are buying PrEP online:"
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"text": "www.fda.gov/InternationalPrograms/PEPFAR/ucm119231.htm"
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"text": "Sometimes buying PrEP online means it might take a while for the drugs to arrive. It is best to order at least a month in advance."
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"text": "You need a combined pill that contains both tenofovir (TD, TDF or TAF) and FTC (emtricitabine). For example, you need Tenvir-EM or Ricovir-EM rather than just Tenvir or Ricovir."
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Page 12
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"text": "Some clinics will support you and provide advice and testing if you buy PrEP online. However, the NHS is only responsible for meds that it supplies."
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"text": "First, please talk to a health adviser, nurse, doctor or community worker. These people can help you if you want to start PrEP, or are already taking it."
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"b": 273.0448
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"text": "Then it is essential to have an HIV test before or as you start."
},
{
"id": "p12.10",
"order": 10,
"type": "text",
"bbox": {
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"t": 265.8468,
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"text": "If you are already HIV positive and don't realise it, you could develop drug resistance."
},
{
"id": "p12.11",
"order": 11,
"type": "text",
"bbox": {
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"t": 230.5765,
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"text": "Ask for a 4th generation HIV blood test. This is also called an antigen/antibody test. This will tell you if you have HIV so long as you haven't had other risks in the last six weeks."
},
{
"id": "p12.12",
"order": 12,
"type": "text",
"bbox": {
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"text": "Most finger prick tests are currently 3rd generation. This test needs 2-3 months to show a positive result. Don’t rely on a finger prick test before PrEP if you have a more recent risk."
},
{
"id": "p12.13",
"order": 13,
"type": "text",
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"text": "If you are just starting PrEP and had a risk in the last six weeks, have another 4th generation HIV test six weeks after starting. This is to be sure an early infection is not missed."
},
{
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"text": "February 2024",
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Page 13
15 item(s)
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footer (2)
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1 · HEADER
2 · TEXT
3 · TEXT
4 · HEADING
5 · TEXT
6 · HEADING
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8 · HEADING
9 · TEXT
10 · TEXT
11 · TEXT
12 · TEXT
13 · TEXT
14 · FOOTER
15 · FOOTER
Page 13 JSON
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"text": "Be careful about starting PrEP if you have flu-like symptoms and had a recent HIV risk. This is in case these symptoms are related to a recent HIV infection."
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"text": "If you are starting PrEP after PEP, it is best to start straight away if you need to. Ideally you should have a 4th generation HIV test after you finish PEP/start PrEP. Then have another test six weeks after starting PrEP."
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{
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"text": "Check your kidneys",
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"text": "A kidney test just involves a blood test for creatinine. This should ideally be done just before or on the day you start. Some clinics might still test for protein in a urine sample."
},
{
"id": "p13.6",
"order": 6,
"type": "heading",
"bbox": {
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"text": "Check for other sexually transmitted infections (STIs)",
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},
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},
{
"id": "p13.7",
"order": 7,
"type": "text",
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"text": "Testing for HIV and STIs is a great idea for anyone with an active sex life. This is whether you use PrEP or not."
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{
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"type": "heading",
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"text": "Hepatitis B (hep B, HBV)",
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{
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"text": "Testing for hep B is essential. This is because PrEP meds are active against both HIV and HBV."
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{
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"type": "text",
"bbox": {
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"text": "This is a good time to have this vaccine, or to boost a previous vaccine. Please ask your clinic about this."
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{
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"type": "text",
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"text": "People with hep B need to take PrEP every day, with medical advice, especially if you want to stop."
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{
"id": "p13.12",
"order": 12,
"type": "text",
"bbox": {
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"text": "Stopping PrEP can lead to rapid inflammation in the liver."
},
{
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"order": 13,
"type": "text",
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"text": "This can be very serious. It can lead to hospitalisation and in rare cases can be fatal."
},
{
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"text": "February 2024",
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Page 14
17 item(s)
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1 · HEADER
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3 · TEXT
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5 · LIST
6
7
8
9
10
11 · HEADING
12 · LIST
13
14
15 · TEXT
16 · FOOTER
17 · FOOTER
Page 14 JSON
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"text": "Once you have started PrEP, monitoring is just as important. If you are currently using PrEP and have not been monitored, talk to the clinic about doing this now."
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"text": "Have a 4th generation HIV blood test. This is also called an antigen/antibody (Ag/Ab) HIV blood test.",
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{
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"text": "Have a full screen for other STIs.",
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"text": "An additional blood test for kidney function (creatinine) might be needed every six months. This is if you are older than 40 or are at risk of kidney problems. Abnormal kidney results might need monitoring more often.",
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},
{
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"text": "Some clinics are now happy for PrEP users to alternate quarterly monitoring between clinic visits and self-sampling postal kits.",
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{
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"text": "Some clinics might arrange for six-monthly prescriptions for PrEP.",
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"text": "Every 12 months",
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{
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"text": "Have a blood test to check your kidney function."
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"text": "Test for hepatitis C if you are having sex with gay men. Some clinics do this more frequently depending on risk.",
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"text": "Testing might also be individualised if you are not having sex very often."
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Page 15
15 item(s)
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1 · HEADER
2 · HEADING
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8 · TEXT
9 · HEADING
10 · TEXT
11 · TEXT
12 · HEADING
13 · TEXT
14 · FOOTER
15 · FOOTER
Page 15 JSON
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"text": "How to start and stop oral PrEP",
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"text": "Starting",
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"text": "Everyone now has the option to start oral PrEP using a double dose (two pills) for the first dose BEFORE sex. This gives protection within two hours."
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{
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"text": "Continuing",
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{
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"text": "Daily dosing then involves continuing with a single pill every day at roughly the same time."
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"text": "For daily PrEP, current guidelines recommend at least six daily doses a week. Although studies suggest fewer weekly doses might be okay, it is not yet clear if this will be included in the 2024 guidelines update."
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{
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"text": "But if you stop PrEP for a week, please restart using a double dose and take seven daily post-sex doses that week."
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"type": "heading",
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"text": "Stopping",
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{
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"text": "If you are using event-based dosing, continue daily dosing for either another two days (2:1:1 dosing) or seven days (2:7 dosing). See pages 17 to 20."
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{
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"type": "text",
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"text": "Before stopping daily dosing, please continue for either two or seven days after you last had sex. This depends on how you are dosing PrEP. See p16 and 17."
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{
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"order": 12,
"type": "heading",
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"text": "TAF and TD",
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"text": "TAF/FTC can be dosed the same way as TD/FTC. Although there is less data on vaginal and neovaginal sex this should still be okay."
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"text": "February 2024",
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Page 16
12 item(s)
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1 · HEADER
2 · HEADING
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6
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9
10
11 · FOOTER
12 · FOOTER
Page 16 JSON
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"text": "Daily PrEP",
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{
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"text": "Most PrEP studies have used daily PrEP.",
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"text": "Taking PrEP every day makes sure that there are protective drug levels 24 hours a day, 7 days a week, even if you don't have sex. This means you can have sex anytime, without planning for PrEP."
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"text": "If you generally have sex every week, daily PrEP might be an easier routine. After the first week, daily dosing needs at least 6-7 doses a week (unless you can use 2:1:1 dosing)."
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"text": "Guidelines later in 2024 might recommend less strict adherence. This could make PrEP easier for women and trans and non-binary people."
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"text": "Quick-start daily dosing using a double dose (two pills) for the first dose. This will protect you within two hours. The pre-dose is important for the highest protection. But if you miss or are late with the pre-dose, start with a double dose as soon as possible."
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"text": "Once on PrEP, continue taking daily PrEP for at least six days each week. This might change when guidelines are updated.",
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"text": "There is currently no data about neovaginal sex. Starting with a double dose and then using daily dosing is therefore a conservative recommendation."
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Page 17
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"text": "Event-based dosing involves only using PrEP when you want to have sex.",
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"text": "Start with a double dose (two pills) at least two hours before you are going to have sex. However, instead of continuing to take daily PrEP you only continue for either two or seven days – depending on the type of sex you have."
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"text": "Event-based dosing is just as effective as daily PrEP. It is often used by people who have sex less often than once a week and who usually know when they might be likely to have sex."
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"text": "Event-based dosing needs fewer pills, but it can't be used if you have hepatitis B."
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"text": "2:1:1 dosing involves starting with a double dose and then taking daily PrEP for two days after sex. Each dose should be roughly 24 hours after the previous one."
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"text": "2:1:1 dosing can be used by anyone for anal sex (if you are the insertive or receptive partner) or insertive vaginal/frontal sex. It can not be used for receptive vaginal/frontal sex."
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"text": "2:7 dosing involves starting with a double dose and then taking daily PrEP for seven days after sex. Each dose should be roughly 24 hours after the previous one."
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"text": "2:7 dosing needs to be used by cis women and trans and non-binary people who are having receptive vaginal/frontal sex."
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"text": "The pre-dose is important for the highest protection when using event-based dosing. But if you miss or are late with the pre-dose, start with a double dose as soon as you can."
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"embedded_text": "BEFORE SEX AFTER SEX st st\n2\t\n 2\t\n PrEP\t\n tablets\t\n ablets\t\n a a t\t\n t\t\n l l east\t\n east\t\n 2 2 h h ours\t\n ours\t\n & & n ot\t\n 1\t\n 1\t\n P P rEP\t\n rEP\t\n t 2 ablet\t\n 4\t\n hours*\t\n 24h\t\n a a 7er\t\n 7er\t\n t t he\t\n he\t\n 1 1 2 2\t\n 2\t\n \nideally\t\n more\t\n than\t\n 24\t\n h 2 ours\t\n 4\t\n hours\t\n b efore\t\n before\t\n sex\t\n sex\t\n 1\t\n 1\t\n P P\n2 PrEP pills 2 to 24\nhours before sex.\ns ex *2\t\n hours\t\n before\t\n or\t\n a7er\t\n planned\t\n <me\t\n is\t\n OK\t\n \nse x\t\n \n23.00\t\n 19:00\t\n \nFRI\t\n SAT\t\n SUN\t\n MON\t\n TUE\t\n WED\t\n THU\t\n FRI\t\n \nWED\t\n THU\t\n FRI\t\n SAT\t\n SUN\t\n MON\t\n TUE\t\n WED FRI\t\n \n18.00\t\n 16.00\t\n -‐\t\n 16.00\t\n -‐\t\n \n22.00\t\n 22:00\t\n 20.00\t\n 22:00\t\n 20.00\t\n \nIt doesn’t matter if you don’t take\nyour PrEP exactly at 22:00\n2 hours before or after is ok\nFINAL\nDOSE"
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"text": "If you might have sex on Thursday take a double dose at least two hours before you have sex."
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"text": "Then take a single pill for the next two days. This should be roughly 24 hours and 48 hours after the first double dose."
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"text": "These times can be approximate. You still get good protection even if you have sex earlier or later than planned. Even if the pre-dose is only just before or even after sex, some PrEP is always better than none."
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Page 19
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"text": "If you have sex over a few days, keep taking a pill each day. Continue for two days after the last day you have sex."
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"id": "p20.3",
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"b": 463.3124
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"text": "2:7 dosing is sometimes needed by cis women and trans and non-binary people having receptive vaginal/frontal sex."
},
{
"id": "p20.4",
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"type": "heading",
"bbox": {
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"text": "BEFORE SEX",
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"text": "2 PrEP pills 2 to 24\nhours before sex."
},
{
"id": "p20.6",
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"text": "AFTER SEX",
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},
"text": "1 PrEP pill every day\nfor seven days."
},
{
"id": "p20.8",
"order": 8,
"type": "figure",
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"l": 70.5175,
"t": 388.566,
"r": 103.4575,
"b": 348.606
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{
"id": "p20.9",
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"type": "text",
"bbox": {
"l": 255.2189,
"t": 382.9345,
"r": 324.5405,
"b": 369.0183
},
"text": "Total = 9 pills."
},
{
"id": "p20.10",
"order": 10,
"type": "figure",
"bbox": {
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"t": 346.7045,
"r": 376.8316,
"b": 256.7293
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"text": "",
"attrs": {
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"embedded_text": "WED\t\n THU\t\n FRI\t\n SAT\t\n SUN\t\n MON\t\n TUE\t\n WED FRI\t\n \n22.00\t\n 22:00\t\n 22:00\t\n \nIt doesn’t matter if you don’t take\nyour PrEP exactly at 22:00\n2 hours before or after is FINAL ok\nDOSE"
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"text": "If you are a cisgender woman, or are transgender or non-binary, having receptive vaginal or frontal sex might need daily PrEP to continue for seven days."
},
{
"id": "p20.13",
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"type": "text",
"bbox": {
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},
"text": "This is for situations when you didn't take at least four doses of PrEP the previous week."
},
{
"id": "p20.14",
"order": 14,
"type": "text",
"bbox": {
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"r": 361.2402,
"b": 119.4871
},
"text": "Start with a double dose before sex and then take daily PrEP for seven days after sex, at roughly the same time each day."
},
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"order": 15,
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"text": "February 2024",
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Page 21
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16 · FOOTER
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Page 21 JSON
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"text": "If you are taking daily PrEP, then do not worry if you sometimes miss one or two pills."
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"text": "Everyone taking daily PrEP will get good protection so long as you take at least four pills every week."
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"text": "Event-based dosing really needs all the recommended doses."
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"text": "If you are late or miss a pill, just take it as soon as you remember and then continue as recommended."
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"text": "Drug levels will still be high enough to protect against HIV. If you often miss doses perhaps it would be better for you to use daily dosing."
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"text": "Everyone should now start PrEP with a double dose."
},
{
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"bbox": {
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"text": "A pill box makes it easy to see if you missed a dose.",
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{
"id": "p21.7.6",
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"text": "Aim for the same time each day. Link it to a routine task like brushing your teeth."
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"text": "If you have risks during a break from PrEP, remember to also have another HIV test.",
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"text": "With event-based dosing, if you miss the BEFORE dose, still take a double dose asap AFTER sex, and continue single daily doses. Contact your clinic in case PEP is recommended (see p22).",
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"text": "February 2024",
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Page 22
18 item(s)
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1 · HEADER
2 · HEADING
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9 · TEXT
10 · HEADING
11 · TEXT
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16 · LIST_ITEM
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Page 22 JSON
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"text": "Having active hepatitis B needs daily PrEP, every day.",
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"text": "Is PEP recommended if I am on PrEP?",
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"text": "PEP stands for post-exposure prophylaxis and involves taking a combination of three HIV meds for one month."
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"text": "PEP is now used less often. But if you need PEP, the earlier you start, the more likely it is to work."
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Page 23
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1 · HEADER
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9 · TEXT
10 · TEXT
11 · TEXT
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15 · FOOTER
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Page 23 JSON
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"text": "Take a double dose of PrEP asap (if you still have some). This will cover you while you are trying to access PEP.",
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"text": "As with the flexibility for dosing, you might decide that you want to stop PrEP altogether."
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"text": "Please discuss this with your clinic."
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"text": "You might want to discuss this with your partner(s) and get tested for HIV and other STIs together. Use a 4th generation HIV test six weeks after the last time you had sex."
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"text": "If you were using event-based dosing then stop after your last planned dose. This will be after two days with 2:1:1 dosing or seven days with 2:7 dosing."
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"text": "It is always easy to restart PrEP in the future if your circumstances change again."
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Page 24
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"text": "PrEP in Scotland\nwww.prep.scot\nPrEP in Wales\ntinyurl.com/v4d5796z\nPrEP in N. Ireland\nrainbow-project.org/prep\nIMPACT trial\nprepimpacttrial.org.uk\nDrug interactions\nhiv-druginteractions.org\nPrEP guidelines\nbashh.org and bhiva.org\nHPV vaccine for gay men\ni-base.info/htb/31151"
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