PrEP - Medication that reduces the risk of contracting HIV

What is PrEP?

PrEP is a preventive measure that involves HIV-negative people taking medication that reduce the risk of contracting HIV through sex. PrEP does not protect against other sexually transmitted infections (STIs) or against pregnancy. PrEP cannot cure HIV.

In this booklet, PrEP refers to a combination of two HIV medicines (emtricitabine/tenofovir disoproxil) in a single pill. This pill has been used for many years as part of HIV treatment but combined with other HIV medicines.
PrEP was approved in Sweden in 2016 for daily use in people at high risk of HIV and was included in the pharmaceutical benefit scheme (high-cost protection).

Some other countries have started to use other types of HIV drugs as PrEP, but in Sweden emtricitabine/tenofovir disoproxil is the only drug which has been approved so far.

How does PrEP work

PrEP blocks an enzyme called reverse transcriptase, which prevents the HIV virus from establishing an infection in the body. PrEP cannot get rid of the virus from the body of someone who is already carrying HIV!

PrEP is taken as a pill, preferably with food. It is important to take the pill at approximately the same time each day, which also helps to establish a routine so that pills are not forgotten. Missed pills reduce the protective effect.

Side effects

You may experience mild nausea or headaches in the first few weeks. In most cases, these side effects disappear after a few weeks or when the treatment is stopped.

More serious side effects related to the kidneys and loss of minerals from the bones are rare but do occur. Some people may develop an increased creatinine level. Creatinine is a measure of kidney function and is determined by blood and urine tests. A small increase does not necessarily mean you will have to stop treatment, but it is important to have your creatinine levels checked regularly.

PrEP can also have an adverse effect on the liver if you have chronic hepatitis or other liver disease. PrEP is not affected by alcohol. Nor does PrEP cause any sexual side effects.

Keep in mind that other medications can affect PrEP (and vice versa). It is important that you inform other healthcare providers that you are using PrEP so that there are no risks of interactions that could lead to lack of protection or to side effects.

How should PrEP be used?

PrEP can be taken during different periods of your life depending on your needs. It is important that you discuss with us at the clinic what might work best for you. PrEP cannot be used as a ‘day-after pill’. Nor should PrEP ever replace HIV testing. As far as we know today, there is no limit on how long you can take PrEP. This assumes that you can tolerate the medicine and have regular follow-up tests.

Before you start PrEP, it is very important to get an HIV test. This is to ensure that you are not already carrying the virus. If you take PrEP while unknowingly being infected with HIV, there is a high risk that the virus will develop mutations leading to resistance. The same is true for hepatitis B, as PrEP is also effective against this virus.

A reliable HIV test is now available as early as 6 weeks after possible infection, provided the test is analyzed in a laboratory. For rapid respond tests, 8 weeks must have passed since the last date of possible infection.

PrEP is prescribed for only 3 months at a time at face-to-face appointments at the clinic, and continued prescription requires you to attend for regular STI/HIV testing. You must not share the pills with others, as treatment should not be started without prior medical consultation and testing.

We recommend that you do not buy PrEP online without prescription, as it is difficult to know for sure that such pills contain the right medication. Unregulated contents may lead to a lack of protection or to side effects.

Here are some different ways of taking PrEP:

Daily PrEP

This is what is primarily recommended in Sweden and has the best documented effect. This means that you take one pill a day, at about the same time. Taking daily PrEP has a reliable protective effect for all patient groups and sexual practices (oral sex, vaginal sex, anal sex). If you have chronic hepatitis B, daily PrEP works well, but it is important that you also receive specific information from your doctor about what applies in your case.

Example 1: “I use Grindr, Planet Romeo and Scruff and may unexpectedly hook up with someone on weekdays as well as during weekends.”

Example 2: “I have sex every now and then, quite irregularly... but as I take pills every day anyway for a different medical condition, it’s easy for me to remember to take the PrEP pill.”

"On demand PrEP"

This is an alternative way of taking PrEP, which involves taking two pills at least 2 hours before sex, and then continuing to take one pill daily until two days have passed since the last time you had sex.‘On demand’ is less well documented, so we don’t know if it provides the same level of protection as daily PrEP. ‘On demand’ is less safe for vaginal sex and people with a vagina are therefore recommended to use daily treatment instead.

‘On demand’ also requires you to be vaccinated or immune to hepatitis B. Taking PrEP ‘on demand’ is unsuitable for those with chronic hepatitis B, as it can lead to the development of resistance.

Example 1: ”Out clubbing on Friday night and I will have sex, but then I won’t have any more sex for the rest of the weekend”.

Two pills on Friday evening, one pill on Saturday evening, one pill on Sunday evening.

Example 2: ”A weekend with a lot of sex even on Saturday and Sunday”.

Two pills on Friday evening, one pill on Saturday evening, one pill on Sunday evening, one pill on Monday evening, one pill on Tuesday evening.

Example 3: ”A week in Gran Canaria”.

Two pills the day of departure, then continue with one pill daily, until two days after returning home.

If you are planning to take PrEP ‘on demand’, we recommend that you still start taking PrEP daily for the first month to see how well you tolerate the pills and check that your tests are fine at the first follow-up appointment. Follow-up tests every 3 months are recommended regardless you choose to take the pills daily or ‘on demand’.

Should I still use a condom?

Condoms are the only form of protection against both HIV and other STIs. Getting an STI can be an unpleasant and painful experience. We recommend that you continue to use a condom together with PrEP when having sex (oral, vaginal, anal). You can discuss strategies to reduce the risk of contracting STIs with us at the clinic.

First PrEP appointment and plan for follow-up appointments

Starting PrEP:

• You will be asked to fill in a written questionnaire about risky sexual behaviour
• You will have the opportunity to talk about the pros and cons of PrEP with 
  knowledgeable healthcare providers
• You will be able to discuss the risk of side effects; this is especially important if you are taking other medicines
• HIV testing and testing for other STIs, including hepatitis B and C
• Blood and urine tests to assess kidney function
• If you have not been vaccinated for hepatitis A and B, we strongly recommend this
• Do you have chronic hepatitis? PrEP can affect your liver. Discuss this with us.

Follow-up tests every 3 months are recommended whether you choose to take PrEP daily or ‘on demand’.

PrEP testing after 1 month:

• Discussion about compliance and possible side effects
• HIV, blood and urine tests to assess kidney function

PrEP testing every 3 months

• Discussion about compliance, safer sex, risk reduction
• HIV testing and testing for other STIs

Additionally every 6 months

• Blood and urine tests to assess kidney function

Additionally every 12 months

• Hepatitis C
• Written questionnaire about risky sexual behaviour

Prescription renewal

The first prescription will be sent by the doctor a few days after your appointment, when the results are expected to be finalized from the lab. This prescription is ‘visible’ to all pharmacies in Sweden and in your shared electronic health records. That is, if you have a Swedish personal number. If you do not have a Swedish personal number the prescription will be sent to a specific pharmacy.

At the 3-monthly check-ups, the nurse will give you a date a few days later when the test results are expected to be done, and the doctor will send a prescription for 3 months.

Emtricitabine/tenofovir disoproxil is covered by the pharmaceutical benefit scheme (high-cost protection), and the pharmacy will give you the cheapest alternative. Prices are constantly changing, so you may be given a different brand each time. All brands contain the same active substance.

Stopping PrEP

PrEP is not for everyone. If you have side effects or find it difficult to take the pills as prescribed, choose an alternative strategy to protect yourself against HIV. Remember to still get tested regularly for HIV, hepatitis and other STIs!

The text on this page is based on the booklet ‘PrEP Fakta’ (‘Facts About PrEP’), with permission from Närhälsan Kunskapscentrum för sexuell hälsa, Västra Götaland.

Do you have any questions?

Contact the clinic through www.1177.se(Extern länk).