The Covid-19 outbreak has caused a marked change in our daily routines. With Ontarians being told to stay at home and health care resources focused on the outbreak, health care providers have begun providing many routine health services remotely, including PrEP-related care. Many Ontarians are also changing their social habits to limit contact with other people, including reducing their number of sexual and drug using partners.
If you are a health care provider prescribing PrEP:
Many laboratories have reduced hours and staffing and are not allowing more than one patient in the lab at a time. For patients who need testing and/or bloodwork, recommend they call the lab to make an appointment to reduce waiting and encourage physical distancing.
For patients who have been stable on PrEP and adherent to daily dosing, it may be reasonable to forgo bloodwork for three months while the COVID-19 pandemic peaks. Patients who have had at least two consecutive creatinine results within the normal range and have not had significant increases in creatinine from baseline could do testing in six months rather than three. STI testing can be done during this time based on symptoms. Once the COVID-19 restrictions have been eased, go back to routine testing every three months.
For new patients who wish to start on PrEP, the guidelines suggest baseline bloodwork plus a repeat HIV test within one month to reduce the likelihood of missing an acute seroconversion. Assess the need for one-month repeat testing on a case-by-case basis: patients who have not had any unprotected sexual encounters in the four weeks before the screening bloodwork can have routine follow-up at three months and the one-month testing can be avoided.
During this time of social distancing, many patients are reporting no sexual encounters and wish to stop PrEP. For patients with no HIV risk (i.e. no sexual encounters or needle sharing at all) stopping PrEP is reasonable at this time. Counsel patients to continue taking PrEP for at least 48 hours after their last sexual encounter.
Patients who stop PrEP and are abstinent during the time of the pandemic can restart PrEP without any additional testing and resume the regular HIV and creatinine screenings every three months.
Patients who have any episodes of condomless sex or needle sharing during the time they are off PrEP should be re-screened before restarting PrEP.
Studies have shown a significantly increased risk of HIV seroconversion in the six months after stopping PrEP, likely due to an increase in unprotected sex while patients were on PrEP; for many patients continuing PrEP may be the safest course given the current uncertainty about how long physical distancing restrictions will continue.