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What’s New in the Guidance for the Use of Pre-exposure Prophylaxis (PrEP) for the Prevention of HIV Acquisition in British Columbia (BC) – August 2019 Update?
The 2019 update to the Guidance for the Use of Pre-exposure Prophylaxis (PrEP) for the Prevention of HIV Acquisition in BC includes several revisions, intended to update clinical practice guidelines based on the developing evidence base and to clarify specific points in clinical care.
PrEP program funding in BC
Since January 2018, PrEP has been publicly funded in BC for individuals who meet the eligibility criteria outlined in this document. The guidelines have been updated to reflect this program, including a detailed assessment of the epidemiology of new HIV infections and diagnoses within BC, existing evidence for effectiveness, and where PrEP may have maximal impact at reducing HIV transmission.
Graded recommendations for PrEP for transgender MSM and TGW
Based on updated evidence, changes have been made to the graded recommendations for the use of PrEP for TGW (updated from GRADE B to GRADE C recommendation). An additional GRADE D recommendation was added for transgender MSM.
On demand PrEP
Based on evidence that on-demand oral PrEP is effective at preventing HIV infection among high-risk MSM, the current guidelines include an alternative on-demand PrEP dosing schedule which can be considered for cis-gender MSM (GRADE B recommendation). PrEP prescribing guidelines have been updated to reflect this alternative dosing schedule. Note that the on-demand PrEP dosing schedule remains “off-label” in Canada.
Assessment for PrEP
Guidelines have been updated to clarify the recommendation for confirmation of a negative HIV antigen/antibody (Ag/Ab) test within 15 days before starting PrEP medication.
Renal dysfunction
Guidelines have been updated to increase clarity with regard to renal dysfunction and PrEP discontinuation. They now highlight that if renal dysfunction develops such that the eGFR falls to <60 mL/min on two measurements, at least two to four weeks apart, then FTC/TDF should be discontinued. The updated guidelines also indicate if there is persistent significant proteinuria on at least 2 occasions or severely increased albuminuria (UACR >30 mg/mmol), PrEP should be discontinued regardless of eGFR. If UACR is >60 mg/mmol, refer to nephrology.
Minor revisions were also made to add references, and update content based on new publications, cited guidelines and source materials.