Pre-Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP)

Two important methods for preventing HIV using medication are pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). PrEP involves administering antiretroviral medications to HIV-negative individuals to prevent infection. PrEP is taken before having a potential HIV exposure to reduce the risk of infection. It can be taken on a regular basis as directed by a medical provider or before a sexual encounter and afterwards to minimize risk.

Access to comprehensive PrEP is a key component of the National HIV/AIDS Strategy for the United States. As of 2021, there are two types of anti-HIV drugs that have been approved as PrEP tablet options depending on what may work best for an individual. The two types of tablets that have been approved as PrEP are Truvada® and Descovy®. In 2012, the U.S. Food and Drug Administration (FDA) approved Truvada® as the first drug to reduce the risk of transmitting HIV. Then in 2019, the FDA approved the use of Descovy® in male adults and adolescents but not for females, due to a lack of studies in this population. Both tablets include a drug called emtricitabine. Truvada also includes the drug tenofovir disoproxil fumarate, while Descovy includes the drug tenofovir alafenamide. Additional drugs are currently being studied for PrEP but have not yet been approved by the FDA. When taken as prescribed, PrEP is highly effective in reducing the risk of HIV infection and is even more effective when used in conjunction with condoms and other prevention strategies.

Estimates from the Centers for Disease Control and Prevention (CDC) suggest that many people at high risk for HIV are not taking PrEP. In an effort to increase the number of people who could use PrEP to reduce risk of HIV but may face various barriers to accessing the medication, in 2019, the U.S. Department of Health and Human Services started a campaign called Ready, Set, PrEP. The program provides free PrEP to people living all over the country including tribal lands and territories.

When people know they have been exposed to HIV, post-exposure prophylaxis (PEP), or antiretroviral medication, has also been shown to reduce the risk of HIV. PEP may be used in non-occupational settings when a person has an unprotected sexual encounter with an HIV-positive person or may be used in occupational settings, such as when a healthcare worker is stuck with a needle used on an HIV-positive person. The PEP regimen must be initiated within 72 hours after possible exposure to HIV, though beginning the medication sooner is more effective in preventing HIV.

Examples of Rural Programs Using HIV Medications to Prevent Transmission:

Health Services Center is a community-based organization in Alabama that offers PrEP services as a preventive method for those at high risk of HIV. Along with providing PrEP medications free of charge, the Health Services Center also continually monitors people on a PrEP regimen, educates people about important HIV prevention strategies, and tests for other sexually transmitted infections prior to starting a person on PrEP.
The Colorado Health Network (CHN) utilized a funding opportunity offered through the Colorado Department of Public Health and Environment Public Health Improvement Plan, which aims to improve access to PrEP drugs for high-risk individuals. CHN used these funds to hire additional clinicians and office staff dedicated to work solely with PrEP patients.
The Dakotas AIDS Education and Training Center (DAETC) works with 10 community health centers in the Dakotas to educate healthcare providers about HIV treatment and prevention methods for their largely rural and tribal populations. Oklahoma is one of seven states identified to receive extra federal resources to target prevention under the Ending the HIV Epidemic initiative, as it is a rural state with high rates of HIV transmission. As part of the HIV prevention strategy in Oklahoma, Rapid Start and PrEP programs are available at all county health departments and through additional community organizations and health care providers. Rapid Start programs work to identify new HIV cases quickly through testing and to connect people with antiretroviral treatment as soon as they are diagnosed.

Considerations for Implementation

Pre-exposure prophylaxis (PrEP) is an increasingly important strategy being recommended for the prevention of HIV. Cultural barriers, a lack of community knowledge about PrEP, and access to care barriers all are factors that need to be considered when implementing a program that will utilize PrEP. PrEP is a medication that needs to be prescribed by a healthcare provider in a clinical setting, which can also be a challenge in some communities.

Administering post-exposure prophylaxis (PEP) within the 72-hour time period is a key part of the HIV prevention strategy for this medication. As such, it is important that people are aware of the limited time period available to use PEP.

Some states may have developed strategies and programs to help subsidize or fully cover the cost of PrEP and PEP medications. For example, New York has implemented a plan to help reimburse individuals who qualify for these medications. Many insurance plans also fully cover the cost of these drugs; however, providers should investigate what each patient's insurance will cover prior to initiating these regimens since these medications can be costly and some insurance plans have limitations. In cases where a patient's health insurance does not cover the full cost, the manufacturers of the PEP and PrEP drugs also have their own medication assistance program.

Resources to Learn More

Preventing HIV with PrEP
Website
Provides information and clinical recommendations about PrEP for the general public. Covers several PrEP topics by answering common questions and offers a video discussing the benefits of PrEP.
Organization(s): Centers for Disease Control and Prevention (CDC)

Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2017 Update: A Clinical Practice Guideline
Document
Presents information on the use of antiretroviral preexposure prophylaxis (PrEP) to reduce the risk of HIV infection in adults. Discusses the risks and benefits, Food and Drug Administration (FDA) recommendations for PrEP, follow-up assessments for patients taking PrEP, other prevention methods to be used along with PrEP, and clinical trials that established safety and efficacy of the PrEP regime.
Organization(s): Centers for Disease Control and Prevention (CDC)
Date: 2017

PrEP and Local Health Departments Educational Series
Tutorial/Training
Educational series aimed at increasing knowledge of local health departments and building awareness of how to use and implement PrEP (Pre-Exposure Prophylaxis) for HIV prevention. Discusses the role that local health departments can play in delivering and supporting PrEP for HIV prevention.
Organization(s): National Association of County and City Health Officials (NACCHO)

We Have the Tools to End HIV: Benefits, Barriers, and Solutions to Expanded Utilization of Pre-exposure Prophylaxis (PrEP) in the US Deep South
Document
Describes the high prevalence of HIV/AIDS in the Southeastern portion of the U.S. Highlights the benefits of PrEP as an effective HIV prevention tool. Discusses the barriers to the usage of PrEP among vulnerable populations in the region and the potential methods to overcome the PrEP challenges.
Organization(s): Southern HIV/AIDS Strategy Initiative
Date: 6/2016

Non-Occupational Post-Exposure Prophylaxis (nPEP) Toolkit
Website
Compiles materials and resources for providers to use in clinical settings supporting the use of post-exposure prophylaxis after potential HIV exposure.
Author(s): Southerly, J., Guido, A.A., Morrison, D., et al.
Organization(s): AIDS Education & Training Center (AETC) Program National Coordinating Resource Center