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HIV PrEP Toolkit for Clinicians

What is HIV PrEP

PrEP stands for Pre-exposure Prophylaxis. It is the use of daily or on demand (event-driven) oral antiretroviral therapy (ART) by HIV negative individuals to reduce the risk of acquiring HIV. HIV PrEP refers to ongoing use of ART before and after potential exposure to HIV. This is different from HIV post-exposure prophylaxis (PEP), where a short course of ART is used immediately after a high-risk exposure event.

How does HIV PrEP work?

In Canada, HIV PrEP is currently only available in pill form:

  • Emtricitabine 200 mg/tenofovir DISPROXIL FUMARATE 300 mg (e.g. Truvada®)
  • Emtricitabine 200 mg/tenofovir ALAFENAMIDE 25 mg (e.g. Descovy®)

It works by blocking an enzyme called HIV reverse transcriptase. When it blocks this enzyme, it prevents HIV from making more copies of itself in the body.

Who is HIV PrEP for?

HIV PrEP is for anyone who is at higher risk of HIV infection. A person must be HIV negative to be on HIV PrEP.

HIV PrEP initiation and/or further assessment is recommended for:

1.  Cis- and Transgender Men who have Sex with Men (MSM) and Transgender Women (TGW) with a calculated HIV Incidence Risk Index for men who have sex with men (HIRI-MSM) score ≥ 10. A HIRI score can be completed based on previous, current or potential future sexual and drug use practices.

2.  Cis- and Transgender Men who have Sex with Men (MSM) and Transgender Women (TGW) reporting condomless anal sex and any of the following:

  • Infection syphilis or rectal bacterial sexually transmitted infection (STI), particularly if diagnosed in the preceding 12 months.
  • Use of non-occupational post-exposure prophylaxis (nPEP) on more than one occasion.
  • Ongoing sexual relationship with an HIV-positive partner who is not receiving stable ART and/or does not have an HIV viral load <200copies/ml.

3.  Persons who Inject Drugs (PWID) that report sharing injection equipment and that have an HIV-positive injecting partner who is not receiving stable ART and/or does not have an HIV viral load <200 copies/ml.

4. Other persons who do not fit into the above criteria, including:

  • Those who report condomless vaginal or anal sex and have an ongoing sexual relationship with an HIV-positive partner who is not receiving stable ART and/or does not have an HIV viral load <200copies/ml.
  • Other populations clinically assessed to be at high risk for HIV infection including: unprotected vaginal/anal sex with partners from MSM/PWID population of unknown HIV status, transgender men, gender diverse individuals, or people engaging in sex work.
  • Self-referral: Self-referral for HIV PrEP may be an indication of undisclosed risk and merits further assessment.

If your client does not meet these eligibility criteria for provincially-funded HIV PrEP, you should:

  • Encourage continued STI and HIV screening and testing as needed.
  • Encourage the use of condoms and other harm reduction strategies such as supporting knowledge around sexual health and healthy relationships, linking individuals to mental health and other self-care programs or resources as needed, and use of clean needles or other drug supplies. Some information can be found on the CATIE or the Sex and U websites.
  • Review an individual’s HIV PrEP eligibility and HIRI score (if relevant) on an ongoing basis, as circumstances change over time.

It is important to remember that HIV PrEP is part of a suite of sexual health interventions.  It is not just about the drug.

Prescribing HIV PrEP

Who can prescribe HIV PrEP?

Any doctor that is licensed to practice in BC can prescribe HIV PrEP. Nurse practitioners who have taken the Treatment for HIV Prevention program at the BC Centre for Excellence in HIV/AIDS (BC CfE) can also prescribe HIV PrEP.

If you are a primary care physician or nurse practitioner and you are willing to prescribe HIV PrEP, or you are a registered nurse conducting HIV PrEP assessments, please refer to our PrEP Resources page for all the relevant resources.

If you are not comfortable with assessing clients and prescribing HIV PrEP, please refer your client to another provider who is willing to prescribe HIV PrEP.  Public health STI clinics and primary care centres are good options. You can complete the Prescriber Notification Letter for the individual to bring with them.

How much does HIV PrEP cost?

Provincially-funded HIV PrEP is available through the HIV Drug Treatment Program at the BC Centre for Excellence in HIV/AIDS.

To be eligible for free HIV PrEP, a person needs to be:

  • HIV-negative
  • At substantial risk for HIV infection
  • A current BC resident with Medical Services Plan (MSP) coverage or Interim Federal Health coverage (e.g. Refugee status)

People living in BC without MSP or Interim Federal Health coverage can still get HIV PrEP, though it will not be provincially-funded. To access HIV PrEP, individuals will need to either:

  • Pay for it themselves
  • Seek coverage through a private insurer or extended health care
  • Purchase it through the Davie Buyers Club or GoFreddie

Inuit persons living in BC can access free PrEP through the Non-Insured Health Benefits (NIHB) program; pre-approval from the BC CfE is not required. First Nations and Métis people living in BC can only access free HIV PrEP through the HIV Drug Treatment Program at the BC CfE.

What next?

Starting HIV PrEP

A first-time HIV PrEP prescription is limited to a 30-44 day supply.

If someone intends to continue on HIV PrEP for a longer term, a clinic visit with STI, HIV and kidney testing (Creatinine and urinalysis or Urine albumin to creatinine ratio) is required before the prescription can be renewed. A maximum of 90 days will be supplied for ongoing HIV PrEP prescriptions.

Once on HIV PrEP, the individual will need to be monitored regularly.

Where is HIV PrEP picked up?

HIV PrEP medication must be picked up within 30 days of the authorized prescription date.

  • In Vancouver and the Greater Vancouver area: HIV PrEP can be picked up at St. Paul’s Hospital Ambulatory Pharmacy.
  • Outside of the Greater Vancouver area: HIV PrEP can be delivered to the prescriber’s office, a Health Unit, pharmacy, or other location in collaboration with the prescriber and the BC CfE.

For more information

Download or print our What you need to know about HIV PrEP information sheet for health care providers or share our FAQs about HIV PrEP with your clients (also available SpanishSimplified Chinese or Punjabi).

The following are some key resources for prescribing HIV PrEP and to support individuals to access and continue on HIV PrEP.

These resources have been developed specifically for the British Columbia HIV PrEP program, but may be adapted for a different province with permission.  Please email SmartSexResource@bccdc.ca to inquire further.

HIV PrEP Guidelines

Eligibility / Assessment Tools

  • The HIV Incidence Risk Index (HIRI-MSM) calculator is an interactive assessment tool of a clinical scoring system that can help identify men who have sex with men who may be at a higher risk of potentially getting HIV. The specific risk factors in the HIRI calculator have been associated with a higher likelihood of HIV infection.
  • The Prescriber Notification Letter can be provided to individuals identified as being at high risk for HIV infection and who are eligible for provincially-funded HIV PrEP. This letter is given to individuals to present to a physician or nurse practitioner in circumstances where there may not be a prescriber directly on site during an initial sexual health history and assessment.

Forms

  • The HIV PrEP Program Enrolment and Prescription Request Form is to be completed by a licensed BC physician or nurse practitioner for new HIV PrEP users OR for individuals who have previously received HIV PrEP through the BC Centre for Excellence in HIV/AIDS but who have been off therapy or living outside of BC more than 6 months.
  • The HIV PrEP Lab Requisition Forms include the necessary tests for the initial assessment of HIV PrEP eligibility, as well as the recommended tests for one-month and ongoing quarterly follow-up for individuals on HIV PrEP. Table 3 in the BC HIV PrEP Guidance document summarizes all testing recommendations when an individual is on PrEP. Please note that other tests may be added as per prescriber suggestion. These forms are meant to be a guide; you can choose to use whatever Laboratory Requisition Forms are commonly used in your organization or clinic.
  • The HIV PrEP Prescription Refill Form is a printed form mailed by the BC Centre for Excellence in HIV/AIDs to the follow-up provider specified on the original prescription. This form is pre-populated with the individual’s enrollment information as well as the due date of the next prescription refill. Providers can choose to use this form, or any legal prescription format to refill the HIV PrEP prescription. A new signed and dated refill prescription is required each time that HIV PrEP medication is dispensed.

Other Tools