Pre Exposure Prophylaxis (PrEP)

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PrEP is the use of antiretroviral drugs by HIV-negative people to greatly reduce the risk of getting HIV upon exposure. Unlike PEP, PrEP is taken before any potential exposure to HIV and is usually taken on a daily, ongoing basis. If taken correctly, PrEP is highly effective at preventing the transmission of HIV.

The daily use of PrEP is recommended as an effective HIV prevention strategy for all people who are at risk of HIV acquisition. This includes men who have sex with men (MSM), transgender people, heterosexual people, and people who inject drugs who are at risk of acquiring HIV.

Previously, patients who were interested in using PrEP had to demonstrate that they had high to medium risk of acquiring HIV in the last three months to be considered suitable for PrEP use. The 2019 ASHM PrEP Guidelines, a resource that helps healthcare professionals evaluate a patient’s suitability for PrEP, no longer require a patient to show HIV risk in the last three months, or for their risk to be high to medium, to be considered suitable for PrEP.

Instead, the ASHM PrEP Guidelines recommend PrEP for patients who have been at risk of HIV in the last three months or predict they will be at risk in the coming three months. Healthcare professionals are also recommended to consider the patient’s sexual health and behaviour and their drug use behaviour when evaluating a patient’s HIV risk. Other factors such PrEP use improving quality of life as a result of reduced anxiety about HIV acquisition can also be considered when evaluating a patient’s suitability for PrEP. While the Guidelines provide behavioural examples to assist healthcare clinicians evaluate a patient’s suitability for PrEP, the Guidelines are led by the principle that patients seeking PrEP should not be denied access to it.

While PrEP is recommended as an effective HIV prevention strategy for trans women, limited available research indicates that the use of gender affirming hormone therapy may contribute to reduced PrEP levels in trans women. As a result, strict adherence to daily use of PrEP is especially emphasised for trans women on gender affirming therapy to ensure PrEP’s efficacy as a HIV prevention strategy.

Accessing PrEP

To access PrEP, you need a prescription from a healthcare professional. All General Practitioners (GPs) and authorised nurse practitioners can prescribe PrEP. Your healthcare professional may ask you about your medical, sexual, and drug-use history to evaluate whether you are suitable for PrEP use. They will also require you undergo a sexual health check before you start taking PrEP and 3-monthly HIV testing after you have started using PrEP.

There are now three ways to buy PrEP:

  • If you have a Medicare card, you can buy PrEP at a subsidised cost using the Pharmaceutical Benefits Scheme (PBS) from any Australian pharmacy. However, you will still need to pay a co-payment.
  • if you do not have a Medicare card, you can:
    • get a script for a non-PBS subsidised brand of PrEP medication and get the script dispensed at a community pharmacy. This option may be useful for people without access to a Medicare card and who do not want to import the medication themselves.
    • buy a generic version of the PrEP medication online from a reliable overseas supplier using the Therapeutic Goods Administration’s Personal Importation Scheme. You will still need a script from a doctor. This option may be cheaper than accessing PrEP from a community pharmacy. The PrEP Access Now website has more information on personal importation.

On World Aids Day 2021, the Minister for Health announced that there will soon be broader access to PreP through a new government scheme. New rules will allow easier online access for PreP and over-the-counter sales in pharmacies. Medicare-ineligible people in Australia will have greater access to PreP through this scheme. Medicare-ineligible people include those on temporary student, business, bridging, spousal, or employer sponsored visas. The scheme is still in development and is due to be rolled out from July 2022.

Unlike condoms, PrEP does not protect against other STIs or pregnancy so the use of PrEP may be less applicable within a sex work context. If you are on PrEP, you should talk to your doctor about a regular HIV and STI testing schedule that is suitable to your specific needs. However, if you think or know you have been exposed to an STI, it is recommended you get a STI test in 7 days.

If you would like to know more about PrEP, including how best to access PrEP, contact your local sex worker organisation.

Additionally, refer to the HIV & AIDS page for more information.

PrEP on Demand

You can adjust the way you use PrEP to only use as it is needed. Usually, the way you take PrEP depends on the type of sex you have (anal or vaginal/front hole sex), how regularly you have sex, and how far in advance you know you will be having sex. This section will focus on ‘PrEP on demand’.

PrEP on demand refers to taking PrEP medication before you plan to have sex rather than taking it on a daily basis. It is suitable for people who have intermittent sexual activity and can plan when they have sex and the type of sex they will be having.

This method is only recommended for cis men who have sex with men. PrEP on demand is currently not recommended for any other group.

PrEP on demand is not recommended for trans and cis gender women (including when engaging in anal sex) and men having vaginal or anal sex with women as there is insufficient evidence testing the effectiveness of this way of taking PrEP. For cis gender women, PrEP adherence needs to be higher and more consistent to ensure the drugs reach adequate levels in the vaginal tissue to provide effective protection from HIV. Additionally, it is recommended that people with hepatitis B take daily PrEP to prevent flare ups of hepatitis B infection and to reduce the risk of developing drug resistant hepatitis B. For these reasons, trans and cis gender women, men having vaginal or anal sex with women, and people with hepatitis B are recommended daily PrEP. For people who engage in spontaneous sexual activity without using other forms of HIV prevention strategies, daily use of PrEP is also recommended.

It is argued that the same evidence used to understand the effectiveness of PrEP on demand for MSM can be used to understand the effectiveness of this method for transmen who only have anal sex with cis men. This would indicate that PrEP on demand could also provide adequate protection for transmen who only have anal sex with cis men.  However, due to a lack of research specifically testing the effectiveness of PrEP on demand within this population, the Australian PrEP guidelines only explicitly recommends PrEP on demand for cis men who have sex with men. Transmen at risk of HIV can access daily PrEP.

Generally, PrEP on demand users are recommended to:

  • take two PrEP pills together between 2-24 hours before sex.
  • then 24 hours after the first two pills, take one pill daily until 48 hours have passed after the last time you have sex.
  • if you plan to have sex again before 7 days have passed since the last time you had PrEP, you only need one initial PrEP pill 24 hours before sexual activity.
  • if you resume sexual activity 7 days after the last time you used PrEP, then you need to take 2 PrEP tablets 24 hours before sexual activity, followed by one PrEP pill a day until 48 hours have passed since the last time you have sex.

If you are planning on using PrEP on demand, it is recommended that you consult your HIV clinician to determine whether this method is suitable for you.

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