Using PrEP

PrEP involves more than just taking the pills. Using PrEP safely means getting support from a healthcare provider before you start and for as long as you continue to use PrEP. They can help you decide if PrEP is right for you, order the specific tests you need before starting PrEP, and write a prescription. Then they'll give you additional tests about every 3 months while you're using PrEP and write a new prescription.

The whole process looks like this:

• visit a doctor for tests
• get your prescription
• buy PrEP from a pharmacy or online
• take PrEP according to the dosing regimen you choose
• return to the doctor every 3 months and start the process over again

This site describes the most important things you need to know if you’re using or thinking about using PrEP. For more detailed information, we highly recommend the HIV i-base “UK Guide to PrEP”. The UK-based website I Want PrEP Now is another excellent source of information about getting and using PrEP, and features many short videos that explain things clearly.

The HSE has produced a booklet for PrEP users in Ireland that's adapted from the HIV i-base booklet linked above. There is a version available in English and another available in Portuguese.

The HSE also produced this "Practical Guidance for Healthcare Workers in Ireland on HIV Pre-Exposure Prophylaxis (PrEP)" document. If you’re planning to get your prescription and tests from a doctor who isn’t experienced with prescribing PrEP, such as a GP, you can refer them to that document.

Your doctor may also find this booklet for PrEP prescribers from Mylan useful, as well as this checklist for prescribers from Teva and this checklist for prescribers from Mylan.

It’s very important that you get all of the recommended tests before you start PrEP and while you’re using it.

If a doctor isn’t comfortable providing the full range of support you need, we strongly encourage you to find another one who is. You can ask other PrEP users in Ireland where they get their PrEP support and prescriptions in the PrEP in Ireland Facebook group.

Before you start PrEP

If you are planning to use PrEP as part of your HIV prevention strategy there are a few things you need to do first:

• get a 4th generation HIV blood test to be sure you’re HIV-negative
• get tests for hepatitis B and kidney function
• get a pregnancy test (if appropriate)
• get a prescription
• choose a dosing regimen

It’s important that PrEP be used only by people who are HIV-negative. Although PrEP uses some of the same drugs, PrEP alone is not a complete regimen for treating HIV. So you need to get a 4th Generation HIV blood test to confirm that you’re HIV-negative.

You also need to get a test for hepatitis B. If you have hepatitis B you may still be able to use PrEP, but you should consult closely with a doctor. The drugs in PrEP are also used to treat hepatitis B so you need extra monitoring when you start or stop PrEP. If you have hepatitis B then daily dosing is the only regimen you should use.

The doctor will also order a test to make sure your kidneys are healthy. This is a test that measures the amount of creatinine in your blood. It's a good idea to check this level again at your first follow-up appointment. After that your doctor may only check once or twice a year. Let your doctor know if you have any existing kidney problems.

Some doctors may also use the opportunity to offer you tests for other STIs as well as tests for your liver function. These aren’t required before starting PrEP, but there’s no harm in getting them done if they’re offered. If you’re getting tested for STIs make sure the doctor takes swabs from your throat and anus, as well as a urine sample.

If you haven’t already been vaccinated for hepatitis A and B, this first consultation might be a good time to get that done. The vaccine is free in Ireland for gay and bisexual men. If you’re a gay or bisexual man under age 26, you can also get a free vaccination against HPV.

If you are someone who can become pregnant, this is a good opportunity to have a pregnancy test as well. 

We suggest that you ask your doctor to write the prescription for the generic ingredients in PrEP—'emtricitabine/tenofovir disoproxil'—not for the brand-name 'Truvada'.

While you’re using PrEP 

Once you start PrEP you'll continue to see the doctor every 3 months for additional tests and a new prescription. These tests should include:

• 4th generation HIV blood test
• full STI screen
• kidney test (1-2 times a year)
• pregnancy test (if appropriate)

You’ll need to continue to check your HIV status every 3 months for as long as you continue to use PrEP. You should also get a full STI screen, including a urine sample and swabs. If you can become pregnant, you should get a pregnancy test as well.

Your doctor should periodically check to make sure your kidneys are still functioning well. If you are under age 40 with healthy kidneys, once a year may be enough. If you're over 40, it's recommended to check every 6 months. If you have pre-existing kidney issues, your doctor may order these tests every quarter.

These visits are also opportunities to ask questions or to talk about your experience using PrEP. Let the doctor know if you're having trouble sticking to the dosing regimen you've chosen, or experiencing any prolonged side effects.

Finding PrEP support services

The medical tests needed to use PrEP safely and effectively can be ordered by any doctor and can be obtained at any of the regular public STI services. However, you may feel more comfortable attending a clinic that specialises in supporting people using PrEP.

Currently there are two such services in Dublin:

- Dublin’s Gay Men’s Health Service (GMHS) on Baggot Street runs a walk-in PrEP support clinic for gay and bisexual men and trans people. They offer information on how to get and use PrEP, along with a consultation with a supportive doctor who can answer questions about PrEP and provide a prescription. This clinic is open every Thursday morning from 10am to noon

- The Mater Hospital runs a Prevention Support Clinic providing the same range of services to anyone interested in using PrEP. This clinic is by appointment only, and there’s information available about it here. To make an appointment you can email, or just print out and mail in this referral request form.

Other STI clinics in Ireland, including private ones, may also be able to offer you support for PrEP use. In Dublin, Dr. Shay Keating’s STD Clinic in Harold Cross offers PrEP support, as does Himerus Health. You can check their websites for their current fees for PrEP support. If you know of other clinics that specifically offer PrEP support, please let us know.

It’s a good idea to be very clear with the clinic staff about what tests you need and that you’re using PrEP. You can show them this prescriber information sheet from Teva to make sure they understand the range of tests they should order for you.

PrEP is a prescription-only medication, so under Irish law you should have a prescription for PrEP if you’re using it. We recommend that you ask for a prescription for 'emtricitabine/tenofovir disoproxil'—the generic names for the medications in PrEP. In practice, not everyone who is using PrEP is able to get a prescription, but it’s still very important to get the correct tests done on the correct schedule. 

Dosing Regimens

There are a number of different ways that people can choose to take PrEP. If you try one and find it's not well suited for you, you may find another option that works better. If possible, you might want to talk to your medical provider about which option or options you think fit your needs so that they understand how you’ll be using PrEP.

We describe each of the methods briefly below, but encourage you to visit the very useful "How to talk PrEP" page at I Want PrEP Now which describes each method in greater detail along with helpful short videos.

Whatever dosing method you choose, you might find that a pill box can help you remember to take your pill when you're supposed to. If you're having trouble sticking to the regimen you've chosen, let your doctor know.

• Daily Dosing
The most common way PrEP is prescribed is daily dosing: you take one pill every day. That works well for anyone, of any gender, and whether you are having vaginal or anal sex (or both). This is also the only recommended regimen for people using injection drugs or who have hepatitis B.

If you choose daily dosing you'll always have the highest level of protection against HIV. After about a week, enough PrEP builds up in your system that it can continue to provide protection even if you miss a pill occasionally.

You can take the pill at any time that suits you. It doesn't have to be taken at exactly the same time but many people find it's easier to remember if they make it part of a daily routine.

• Event-Based Dosing/On-Demand Dosing/PrEP 211
If you have anal sex but not vaginal sex, there are other options that you can also use. Event-based dosing, also called on-demand dosing or PrEP 211, involves using PrEP only around the time of sex. It's very important to understand exactly how event-based dosing works and to do it correctly every time. Unlike with daily dosing, if you miss even one pill the effectiveness of event-based dosing is greatly reduced.

Although it's fairly easy to do once you understand it, event-based dosing is a little bit confusing to explain. We suggest you read this HIV i-base page which explains how the regimen works in detail and shows several real-life examples. You can also check out this video from I Want PrEP Now, which explains how event-based dosing works.

Event-based dosing is not recommended if you have hepatitis B because it can cause viral flair ups which can damage your liver. If you have hepatitis B you should only use daily dosing, and be sure to consult your doctor if you plan to stop taking PrEP.

• 'The Ts and Ss'–4x weekly
This way of taking PrEP has never been formally studied, but is based on evidence from a number of other PrEP studies. Like event-based dosing, it is suitable only for people who have anal but not vaginal sex, and missing even one dose will significantly reduce the level of protection that it provides.

With 'the Ts and Ss' you take a pill 4 times a week, on the days that begin with a 'T' or an 'S': Tuesday, Thursday, Saturday and Sunday. Used consistently, this method keeps enough medication in your system to be protective on its own, but many people choose to increase to daily dosing during times when they are more sexually active.

• Holiday PrEP
There’s one more option which is sometimes called “holiday PrEP.” This is suitable for people who have anal or vaginal sex. This method is basically daily PrEP, but used only during a pre-planned period of time when you want the high level of protection against HIV that PrEP offers. 

It's recommended that you start taking PrEP about 7 days before the start of the period where you want to be protected, every day during the entire period, and continue for 7 days after the end of the period.

I Want PrEP Now has a very useful page that explains each of the different options in greater detail. We encourage you to have a look and decide what option or options seem best for you.