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 currently using PrEP:
Continue using PrEP as prescribed by your health care provider if you are still having sex and/or sharing needles with others.
PrEP should be taken daily (unless your health care provider has counselled you on intermittent dosing of PrEP). Do not skip doses to prolong your medication.
Research on possible treatment options for Covid-19 have included clinical trials of existing medications, among them antiviral medications used in HIV treatment. News of clinical trials has generated confusion and misinformation about what medications may be effective at treating Covid-19. There is currently no evidence that the medications used for PrEP, tenofovir disoproxil fumarate and emtricitabine, can either treat or prevent Covid-19. Following social distancing guidelines and maintaining proper hand hygiene are the most effective means of preventing Covid-19. For the most up-to-date information about Covid-19 testing and treatment in Ontario visit https://covid-19.ontario.ca/
Pharmacies have been instructed to reduce the amount of medication they dispense to ensure a consistent drug supply. Instead of the typical 90-day supply, pharmacies are only going to dispense 30 days of medication at a time. It’s important to have a consistent supply of PrEP medication so you do not miss doses. Set reminders to refill your prescriptions more regularly.
If you require routine bloodwork to renew your prescription, call your health care provider. You may be able to refill your prescription and continue using PrEP without completing the bloodwork.
If your kidney function has been normal during routine monitoring on PrEP and you have not been missing doses of your medication, it may be okay to temporarily delay your bloodwork. Ask your health care provider about whether you can delay this routine monitoring and when they would suggest restarting it. Do not skip appointments or monitoring without consulting your health care provider as this may result in your health care provider stopping or delaying refills of your medication.
If you are considering stopping PrEP, do not stop your medication until at least 48 hours after your last possible exposure to HIV and do not restart PrEP without health care provider supervision.
During this period of social distancing, you may consider stopping PrEP because you have fewer sexual and drug using partners. Even if your number of partners has decreased significantly, PrEP is still a valuable prevention option if you are continuing to have sex and/or share needles with partners whose HIV status you do not know or who are living with HIV and may not be on treatment.
If you are abstaining from having sex and/or sharing needles during this time, Canadian guidelines suggest continuing PrEP for at least 48 hours after your last possible exposure to HIV. When you decide to begin having sex again, you may need to use other forms of prevention like condoms until you are able to consult with your health care provider about starting PrEP again. PrEP is not effective immediately after restarting medication: if you rely on PrEP as your main HIV prevention option, we recommend you take it daily for 7 days before having anal sex without condoms and for 21 days before having vaginal or front hole sex without condoms or before engaging in injection drug use where you may share needles with others.
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.
Stopping PrEP during COVID-19 may be reasonable; only patients who have had no potential HIV exposures during this period should restart PrEP without repeating baseline screening
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.