HIV Pre-exposure Prophylaxis (PrEP) in GP practices: What do practice nurses need to know?

Nurse sexual health specialist Jodie Crossman explains initiatives to improve access to HIV preventative medication via general practice and what practice nurses need to know

As part of its aim to meet the target of zero new HIV diagnoses by 2030, the UK Department of Health and Social Care has recently launched a roadmap for meeting the PrEP needs of those at risk of HIV.¹ One of the proposed actions is to pilot provision of PrEP in GP practices. Although PrEP is currently only available in sexual health clinics, by increasing the locations in which PrEP is offered it is hoped that those at risk of acquiring HIV may find it easier to access preventative care.

What is PrEP?

PrEP is a medication that offers protection against HIV. A recent trial reported an 86% reduction in HIV transmission in people taking PrEP.²

There are two types of PrEP:

Tenofovir Disoproxil and Emtricitabine (TDF) Brand name: Truvada. Widely available.
Tenofovir Alafenamide and Emtricitabine (TAF) brand name: Descovy. Only currently available in UK sexual health clinics attached to a HIV care provider.

Who should take PrEP?

PrEP is currently recommended for:

Men who have Sex with Men (MSM) and transgender women having condomless anal sex.
HIV-negative individuals having condomless sex with partners who are living with HIV and do not yet have an undetectable virus level.

PrEP should be considered for:

People from, or travelling to, countries with a high HIV prevalence who are likely to have unprotected sex in those countries, or their partners.
People engaging in group sex or polyamorous relationships with both male and female partners.
People with a male partner who is also having sex with men.
People engaged in commercial or transactional sex work.
People in abusive relationships who feel unable to advocate for other forms of HIV risk reduction.

How is PrEP taken?

PrEP can be taken in two different ways:

Daily dosing: Suitable for everyone taking PrEP. One tablet taken each day. Protective concentration is reached within 24 hours for anal sex or seven days for vaginal sex.

Event based dosing: Only suitable for anal sex. Two tablets are taken 2-24 hours before sex, then daily until 48 hours after the last episode of sex.

Patients taking PrEP are advised to test for HIV every three months (usually as part of a full sexual health screen) to reduce the risk of developing drug resistance in the event that they acquire HIV while using PrEP.

What are the side effects?

PrEP has minimal side effects. Many people experience some nausea, but this usually settles after the first few doses.

There is a small risk that PrEP can affect renal function. Annual creatinine monitoring is recommended for users under 40 with no renal impairment.³

For those aged over 40 or those with a risk of renal impairment (for example: hypertension or diabetes) renal monitoring is recommended every 6 months. If renal function deteriorates, patients should be referred to a sexual health service for consideration of TAF PrEP.

Why might someone choose to take PrEP?

Although condoms are highly effective protection against HIV, some people find it difficult to remember ‘in the moment’ or to negotiate their use. PrEP is a medication that can be taken in advance of any sex, giving the user autonomy over their own health.

When should PrEP not be used?

PrEP is generally a very safe medication with minimal interactions. It is safe to use in pregnancy.

It is advised that patients who are displaying symptoms of seroconversion delay starting PrEP until they have a negative HIV test.

People who have had a risk of HIV within the previous 72 hours may benefit from Post-Exposure Prophylaxis, so should be referred to a sexual health service for assessment for this.

Why is PrEP being piloted in primary care?

Although many people, particularly MSM, are aware of and using PrEP, there are groups of people who may not attend sexual health clinics and so may miss messaging about HIV prevention. Providing PrEP in primary care as part of routine healthcare can help to reduce the stigma of HIV, while the opportunity to see patients more regularly for PrEP management may also help to identify other health or social needs that may improve their long-term health.

We aren’t part of a pilot. What can we do in the meantime?

If your practice isn’t part of a pilot, you still play an important role in identifying people who may be at risk of HIV and would benefit from attending a sexual health clinic to start PrEP. Consider opportunities to discuss HIV prevention, for example during travel clinics, smear testing or contraception consultations, and encourage signposting into sexual health services for patients of all walks of life.

Jodie Crossman is nurse team leader at Brighton Sexual Health and Contraception Service, is chair of the British Association of Sexual Health and HIV Nurses and Health Adviser group, and co-chair of the Sexually Transmitted Infections Foundation

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