The guidance on PrEP suitability in this chapter is identical to the guidance provided in Chapter 4 on PrEP suitability. However this chapter is written for clinicians who prefer to and are skilled in evaluating people’s suitability for PrEP according to how the person reports their gender identity and sexuality. For example a person assigned female at birth (cis-female) may identify their gender as male (trans-male) and their sexuality as a man who has sex with men (MSM). In this setting, the clinician would know to evaluate the person’s suitability for PrEP based on the possibility that the person may practice both vaginal and anal sex. Alternatively a person assigned male at birth (cis- male) may identify their gender as female (trans-female) and their sexuality as heterosexual. If this person has undertaken gender-affirming surgery the clinician would then know to evaluate the person’s suitability for PrEP based on the possibility that the person may practice both vaginal and anal sex. This Parallel of Chapter 4 foreshadows a future where all clinicians will be able to skilfully and comfortably evaluate the sexual health of their patients based on how their patients identify their gender and sexuality. For more information see: a language guide: Trans and gender diverse inclusion.
Pre-exposure prophylaxis (PrEP) medications are registered in Australia with the Therapeutic Goods Administration (TGA) and they are subsidised by the Australian Pharmaceutical Benefits Scheme (PBS). All general practitioners and other medical specialists can prescribe PrEP using a PBS streamlined authority arrangement. No specialist training is required to prescribe PrEP, however resources and training guidance are available for clinicians who are new to prescribing PrEP.
People presenting for PrEP are typically at high risk of human immunodeficiency virus (HIV) infection and they should not be dissuaded from using PrEP. To do so is to deny a person access to one of the most effective HIV prevention tools currently available. Doctors authorised nurse practitioners who are not comfortable prescribing PrEP should refer the patient immediately to a colleague, or another service that does provide PrEP.
It should also be highlighted that sexual history taking is a necessary and routine part of medical practice, and when this process identifies that a patient may be at risk of HIV, clinicians should proactively offer these patients PrEP. Furthermore clinicians are encouraged to raise PrEP as an HIV prevention strategy with patients whom they perceive to be at risk of HIV infection, even if the purpose of the patient’s visit is not related to sexual health, sexually transmissible infections (STIs) or drug use.
These ASHM 2021 PrEP guidelines recommend daily PrEP for all people at risk of HIV infection. In addition, these guidelines also recommend that on-demand† PrEP should be offered as an alternative option to cis-gender men who have sex with men (MSM). Please refer to section Providing PrEP for further information on initiating PrEP.
PrEP providers need to obtain a thorough sexual and drug-use history at baseline to determine a person’s suitability for PrEP and to review their ongoing need for PrEP at each 3-monthly clinical review. It is important to acknowledge that a person’s behaviour may change over time, and that a person may wish to continue PrEP even if their current HIV acquisition risk is not high.
These guidelines acknowledge that PrEP should be recommended as an HIV prevention strategy for people who have been at risk of HIV infection during the previous 3 months and who foresee having similar risks in the next 3 months. These guidelines also recommend PrEP for people who have not been at risk of HIV infection during the previous 3 months, but whose circumstances have changed, and they foresee HIV risk occurring in the next 3 months.
Please note that people who are eligible for PrEP based on their sexual behaviour may be simultaneously eligible for PrEP based on their injecting and other drug use behaviour and vice versa.
The following suitability criteria can be used to help structure a discussion with a patient about their sexual health and behaviour. Guidance on how to initiate and guide a discussion about a person’s sexual and drug using behaviour in primary practice is available (1).
Only a small proportion of participants in PrEP studies have been transgender (trans) or gender diverse people (2, 3, 4). As a result, limited data are available for these populations. Incorrect assumptions can be made about trans people and their sexual practices, as they may practice vaginal/neovaginal and anal
intercourse, both insertive and receptive. Trans and gender-diverse people who are at risk of acquiring HIV on the basis of their sexual history are eligible to access PrEP. It is essential for clinicians to take a sexual history using appropriate and sensitive language to assess risk.
Clinicians who have limited experience with prescribing PrEP are encouraged to discuss with a PrEP experienced clinician those patients whose PrEP suitability is unclear.