The document outlines the definition and significance of pre-exposure prophylaxis (PrEP) in HIV prevention, especially in high-risk populations in South Africa. It details criteria for PrEP eligibility, the essential services offered alongside PrEP, counseling requirements, and follow-up protocols. Additionally, it emphasizes the importance of monitoring and reporting for effective program management and ensuring safety during PrEP use.

1. PrEP

2. Outline
• Introduction
• Definition
• Difference between PrEP, PEP, ART
• Provision of PrEP
• PrEP counselling
• PrEP follow up and monitoring
• PrEP monitoring and reporting

3. Introduction
• Human immunodeficiency virus (HIV) is an infection that attacks the body’s
immune system by targeting the body’s white blood cells, weakening the immune
system. This makes it easier to get sick with diseases like tuberculosis, infections
and some cancers.
• South Africa has the largest HIV epidemic in the world, with 7.64 million people
living with HIV in 2019, representing 20% of the global HIV burden.
• WHO recommends supporting and strengthening primary HIV prevention
alongside treatment, as both are needed to meet the 95-95-95 targets.
• According to the WHO guidance, PrEP should be an additional prevention choice
in a comprehensive package of services that also includes HIV testing risk
reduction counselling, male and female condoms, lubricants, ARV treatment for
partners with HIV infection, and voluntary medical male circumcision.

4. Definition
What is PrEP?
• Pre-exposure prophylaxis
• PrEP is defined by WHO as the use of antiretroviral drugs by
HIV-negative individuals who are at substantial risk of
acquiring HIV before potential exposure to HIV to prevent
HIV acquisition. The current preferred regimen in South
Africa is oral TDF/FTC (Tenofovir disoproxil
fumarate/Emtricitabine) as a fixed-dose combination.

5. DIFERENCES BETWEEN PrEP, PEP and A

6. Provision of PrEP

7. Identification of potential candidates for PrEP
• This is Identifying people at greater risk of HIV infection who
may benefit from PrEP and are willing to take PrEP; or who
may, with assistance, be motivated to continue with PrEP is
essential for programme efficiency.

8. Candidates for PrEP
Specific populations considered to be at greater risk of contracting and HIV
infection include:
• Adolescent girls, boys, young women and men
• Men who have sex with men
• Individuals with more than one sexual partner
• People who inject drugs
• People with a recent history of STI(s)
• Individuals who recognise their own risk and request PrEP
• Serodiscordant couples if the HIV positive partner is not virally suppressed
• Sex workers
• Migrant workers
• Pregnant and breastfeeding women

9. Considerations for PrEP in Pregnant and Breastfeeding
Women
• HIV negative pregnant and breastfeeding women at high risk of contracting
HIV
• They must be counselled for and offered HIV prevention interventions
including PrEP together with acute HIV infection screening, adherence
counselling, safety monitoring and three-monthly HIV testing and antenatal
care.
• Any appropriately trained healthcare provider authorised to assess,
diagnose, prescribe, and dispense (doctor, NIMART authorized professional
nurse, and PIMART authorized pharmacist) can initiate and issue PrEP.
• The woman should be informed about the comprehensive HIV prevention
package and care options available for her to choose, emphasizing the
importance of follow up ANC visits with regular HIV testing.

10. Minimum Package of Services Offered with PrEP
The following minimum package of services must be provided to all clients
receiving PrEP services in accordance with national guidelines:
• HIV Testing Services
• Risk reduction counselling
• Voluntary male medical circumcision
• ART initiation for those diagnosed with HIV
• Syndromic STI diagnosis and treatment
• Condoms and lubricants
• Pregnancy screening
• Contraception
• Counselling for Mental Health
• TB Screening
• Voluntary partner HIV testing and treatment

11. Screening for Prep
• Any person requesting PrEP, should be considered for PrEP, even if he/she may not be perceived
to be at risk by the provider.
• To identify individuals who may benefit from PrEP, the healthcare provider should assess the
following individual characteristics and/or behaviour as they increase the individual’s risk for
contracting HIV:
1. Any individual who confirms having sex:
• With out a condom
• With more than one partner
• With an HIV positive partner
• With a partner/s whose HIV is unknown
• While under the influence of alcohol and drug
2. Any individual diagnosed with an STI often or recently
3. Young women or men in age disparate relationships (e.g. with a partner older than 5 years).
• HIV negative individuals who confirm any of the above should prompt a further discussion about
the risks and benefits of PrEP.

12. Criteria used to offer PrEP
• Patient must be HIV negative by routine rapid antibody test.
• Absence of symptoms of acute HIV infection (e.g fatigue, fever,
sore throat, body aches, rash, swollen lymph nodes).
• He/she must be willing and able to take PrEP as prescribed.
• No contraindications to TDF or FTC.
• Adolescents >35kg in weight; if they are less 15 years old, they
should be tanner stage 3 or greater.

13. Contraindications for PrEP
• HIV infection
• Estimated glomerular filtration rate (eGFR) of:
Less than 50mL/min/1.73 m^2 for adults and adolescents ≥
16years.
Less than 80mL/min/1.73m^2 for children and adolescents
10 and <16.
≥
• Serum creatinine greater than 85µmol/L for pregnant
women.

14. Baseline investigations
• Following a negative HIV test and the person confirms that
they are interested in taking PrEP,several baseline
investigations should be conducted before PrEP can be
initiated

16. Prescription of drugs
• The recommended regimen is TDF/FTC 1 tablet orally (PO) once a day.
• The drugs can be taken anytime of the day, with or without food.
• can be stored at room temperature.
• Prescription intervals:
 At initiation : give them 1- month PrEP drug supply.
At 1 month visit: repeat HIV test and provide 3-month prescription
and 3-month PrEP drug supply .
Every 3 months: repeat HIV test and if the client remains HIV negative
provide 3-month prescription and 3-month PrEP drug supply

17. PrEP Counselling
• Client education is critical to the success of PrEP as part of a
comprehensive HIV prevention plan.
• Providers should educate and counsel PrEP users about PrEP
and should provide them with other appropriate prevention
options such as male and female condoms.
• Risk-reduction counselling is a behavioural intervention that
attempts to decrease an individual’s likelihood of acquiring
HIV and other STIs and should be implemented as part of HIV
prevention counselling, with sexual reproductive health and
contraceptive counselling at all follow-up visits for PrEP users.

18. PrEP counselling for pregnant women
• All pregnant women must receive the routine information
and counselling provided to all HIV negative at-risk
individuals.
• The choice to start, continue or discontinue PrEP when a
woman becomes pregnant should be made by the woman,
following discussion of the risks and benefits with her
health-care provider.
• A pregnant and breastfeeding woman should be advised of
the safety, benefits, and side effects of taking PrEP during
pregnancy and breastfeeding.

21. PrEP follow-up and monitoring
Follow-Up procedures for individuals on PrEP, including pregnant women:
• Confirmation of HIV-negative status(At initiation, at 1 month, then every 3
months)
• Address side effects (Every visit)
• Adherence counselling (Every visit)
• Creatinine clearance test (Only if indicated)
• STI screening and treatment (Every visit)
• PrEP medication issuance (1-month supply at initiation, then 3-month
supply)
• Behavioural sexual risk reduction counselling (Every visit)

22. Discontinuation of PrEP
PrEP should be stopped if the client:
• Tests HIV-positive
• Has persistently low eGFR or high sCr levels (in pregnancy))
• Is non-adherent to PrEP
• No longer needs or wants PrEP
• If there are safety concerns where the risks of PrEP use outweigh
potential benefits
NB: For a person stopping PrEP medication should be continued
for 7 days after the last potential HIV exposure to ensure
protection.

23. PrEP and Hepatitis B
• TDF and FTC both have hepatitis B antiviral activity.
Discontinuation of PrEP may cause serious liver damage
resulting from reactivation of HBV.
• PrEP users with chronic hepatitis B should be carefully
monitored when they discontinue PrEP.
• Some PrEP users may opt to continue using tenofovir to
control their hepatitis, even if they no longer require these
drugs for the indication of PrEP.

24. PrEP clients who test HIV-positive
• Taking PrEP after contracting an HIV infection could result in
the development of resistance to the drugs used in PrEP –
tenofovir and emtricitabine – limiting future antiretroviral
treatment options.
• Clients who test HIV-positive must stop taking PrEP
immediately and initiated on ART or referredfor ART as soon
as possible, regardless of CD4 count.
• They must be linked to HIV care, treatment,and support.
• Where possible, their partners should be encouraged to test
for HIV.

25. • HIV seroconversion after initiating PrEP can occur and may
be due to:
- People who take PrEP drugs inconsistently or do not take it
as prescribed.
- People who stop PrEP for a variety of reasons.
• PrEP failure: People who take PrEP consistently as
prescribed and become infected with HIV while taking PrEP.
• All persons on PrEP that have seroconverted must be
reported on the PrEP seroconversion form

26. PrEP Monitoring and Reporting
• Routine monitoring of the PrEP programme is essential to
assess uptake, effective use, and safety.
• The data collected will also assist with forecasting demand
to ensure sufficient and an uninterrupted supply of all the
required commodities.
• To facilitate standardised and systematic monitoring of the
programme, all PrEP service points must use the PrEP
Clinical Form to collect client data
• PrEP providers must ensure that the form is completed in
detail and kept in the client file at the healthcare facility

27. • The information contained in the clinical form must then be
used for entry into TIER.Net after each clinical visit or if
there is a change in the clients status as PrEP user

28. PrEP Programme Indicators

29. References
• 2021 updated guidelines for the provision of oral Pre-exposure Prophylaxis (PrEP) to persons
at substantial risk of HIV infection.

30. Thank you
For listening