Finding a PrEP prescriber
PrEP can be prescribed by various healthcare providers such as an HIV or Infectious Disease Specialist, a Family Doctor or General Practitioner, a Nurse Practitioner, or Pharmacists with additional prescribing authorization. Although not all healthcare providers are knowledgeable about PrEP, the guidance laid out on this website and in the linked resources should provide all the information a provider needs to know to feel comfortable prescribing PrEP for someone who is eligible based on current guidelines.
If you provide this resource to your healthcare provider and they still indicate discomfort providing PrEP, we recommend the following options:
Have them contact us directly here. We can answer some questions your physician might have and/or connect them with an Infectious Disease Specialist who can do the same.
Contact your local HIV, Sexual Health, or LGBTQ organization to find a physician knowledgeable about and willing to prescribe PrEP. To find contact information for a local organization near you, visit our Resource section here.
Once you find a physician who is knowledgeable about and comfortable prescribing PrEP, you can begin the process of determining if PrEP is the right option for you.
Is PrEP Right for You?
Your personal risk of HIV infection is based on a combination of factors. Some of these are personal in nature, such as:
Whether or not you’re having anal and/or vaginal (or frontal) sex
Whether you have a regular monogamous partner or multiple anonymous or casual partners
The HIV status of your sexual partners – i.e. if they are HIV-negative, are HIV-positive with an undetectable viral load, or have an unknown HIV status
Whether or not you effectively and consistently use condoms during anal and/or vaginal (or frontal) sex
Whether you use substances in combination with sex in a way that affects your ability to effectively and consistently use other HIV prevention strategies
Whether or not you inject drugs, particularly if you share injection equipment with others
For example, if someone is in a long-term, monogamous relationship with an HIV-negative partner, or HIV-positive partner with an undetectable viral load (controlled through high adherence to HIV medication), and does not use injection drugs or share injection drug equipment, they are likely at a low risk of HIV infection.
On the other hand, if someone is having anal and/or vaginal (or frontal) sex with multiple partners of unknown HIV status, or HIV-positive partners who have not attained and maintained an undetectable viral load, and does not effectively and consistently utilize condoms, they are likely at a higher risk of HIV infection.
Other factors which can impact your vulnerability to HIV infection have less to do with your personal choices and more to do with structural or systemic factors. For example, certain populations within Alberta experience higher rates of HIV to begin with such as men who have sex with men, people who belong to African, Caribbean, and Black populations, and Indigenous peoples. Therefore, even though two people might make all the same personal choices regarding their sexual behaviour, some individuals might still be at a higher risk of HIV infection because there is a higher rate of HIV within the community they identify with and the sexual networks they belong to.
If, based on your circumstances, you feel that you are at a higher risk of HIV infection, talk to a healthcare provider you trust. They can speak with you about what HIV prevention options are most suitable for you.
One of those options is PrEP. Recently, the Albertan PrEP Guidelines were released to help you and your healthcare provider understand if PrEP is right for you. These guidelines look at various factors to determine whether or not PrEP is the best HIV prevention option for you.
The criteria differ depending on which communities or populations an individual identifies with. The full set of guidelines and eligibility criteria can be found here. However, as an example, here are the eligibility criteria for gay, bisexual, and other men who have sex with men (MSM) and Trans Women and Gender Diverse People:
PrEP is recommended for MSM, Trans Women and Gender Diverse People who report condomless anal sex within the last 6 months and who have any of the following:
Infectious syphilis or bacterial STI, particularly if diagnosed in the preceding 12 months
Recurrent use of nPEP (more than once)
Ongoing sexual relationship with HIV positive partner with substantial risk* of transmissible HIV
High-incidence risk index (HIRI-MSM) risk score ≥11
PrEP is not recommended in the context of a stable closed relationship with a single partner with no or negligible risk of having transmissible HIV.
The decision as to whether or not you should start PrEP should be made within the context of a comprehensive sexual health discussion between you and a healthcare provider you trust. Additionally, the various factors determining your eligibility for PrEP might change over time, meaning that while you might benefit from PrEP now, you might not a year from now. Because of this, it is important that in addition to ongoing screening and monitoring (as laid out in the next section), you continue to have regular discussions about your sexual health with your provider to determine whether or not PrEP remains the best HIV prevention option for you.
Establishing Your HIV Status
If you and your healthcare provider determine that PrEP is right for you, the next step is to establish your current HIV status.
In order to accurately determine your current HIV status, it is important to understand window periods. A window period is the time after someone is infected with HIV within which standard HIV testing will not detect the virus. For example, the test generally used for standard HIV testing in Alberta can begin to detect HIV in as early as 15-21 days, with 95% of tests being accurate after six weeks. And then in rare cases it can take up to three months for an accurate result to be returned.
Because of these window periods, there is a chance that you could receive an HIV-negative test result that may not be accurate. This might happen if your last sexual encounter or potential exposure to HIV occurred within the window period where HIV testing may not yet detect it. For example, if you had a potential exposure to HIV one week ago, standard HIV testing in Alberta would not yet detect it.
This is important to understand when considering taking PrEP, as it’s very important to ensure that you receive an accurate, up-to-date HIV-negative result before starting. If someone unintentionally starts PrEP while HIV-positive, it can result in issues related to medication resistance. The reasons for this are:
PrEP (TDF/FTC) only contains two different HIV medications (tenofovir disoproxil fumarate and emtricitabine). These two medications taken together as PrEP are sufficient to prevent new HIV infection. However, the successful treatment of HIV in someone who is already HIV-positive requires three or more different types of HIV medication (often combined in one single pill). Therefore, PrEP (TDF/FTC) on its own is not sufficient to treat HIV infection.
Because of this, if someone who is HIV-positive begins PrEP, the HIV will not respond effectively to the treatment and can build resistance against the medications in PrEP. If the HIV in someone’s system becomes resistance to these two medications, then these medications – which are quite common in many combination HIV treatment regimens – will no longer be effective treatment options for them. Although there are treatment options which do not contain TDF or FTC, it is not desirable to lose two common HIV medication options for treatment before someone is even diagnosed.
Because of this, your provider will likely take an extra step in determining your HIV status. In addition to standard testing, they will also evaluate you for signs or symptoms related to acute HIV infection within the last twelve weeks. These are signs and symptoms someone might experience soon after becoming infected with HIV but perhaps before standard HIV testing might return an accurate result. Because of this, they can act as warning signs that someone might be HIV-positive even though the tests don’t return a positive result. Some of these signs or symptoms include fever, fatigue, weight loss, or nausea.
These symptoms are common to many other health issues and do not automatically mean you have HIV. However, given the importance of ensuring you’re HIV-negative before starting PrEP, assessing these symptoms can help provide an additional level of certainty when determining your HIV status. If you have experienced signs or symptoms related to acute HIV infection in the last twelve weeks, your provider will likely order follow-up HIV testing within the next one to three weeks just to ensure your HIV-negative result is accurate. During this time, starting PrEP should be delayed.
Finally, if it is determined that your current HIV status is negative and your provider writes you a PrEP prescription, it is important to continue to use other HIV prevention options, such as condoms, until you have taken PrEP for at least seven days for anal sex or twenty days for vaginal or frontal sex. This is to ensure that there is enough PrEP in your body to provide adequate protection against HIV infection. If you are taking PrEP on an intermittent or "on-demand" basis instead of daily, speak with your healthcare provider for more information about achieving steady levels of PrEP in the body for HIV prevention.
Bacterial STI: A sexually transmitted infection (STI) that is caused by a number of different bacterial species such as gonorrhea, chlamydia and syphilis. These are different from other infections such as hepatitis, HPV and HIV which are instead caused by viruses. Most (but not all) bacterial STIs are able to be treated with antibiotics. It is important to note that antibiotics are only used to treat bacterial infections, and are not effective for treating viruses.
HIRI-MSM risk score: HIV Incidence Risk Index (HIRI) is a tool that can be used to identify which MSM individuals are at an increased risk of acquiring HIV. Individuals are assigned scores based on a number of different factors such as age and condom usage. These scores are then totaled, and used to identify people who are at an especially high risk of HIV infection. A score ≥10 generally classifies someone as a candidate for PrEP.
Substantial risk of transmissible HIV: Antiretroviral medication (ARVs) can reduce the copies of virus to a limit that is below the threshold that can be detected by laboratory tests. At this point, an individual is said to have an “undetectable” viral load and is unable to transmit HIV to another person. This is also known as Treatment as Prevention (TasP).
Resistance: The reduced or completely diminished efficacy of a drug caused by genetic changes in the pathogen. In the context of HIV, drug resistance can negatively impact the effectiveness of antiretrovirals used to treat or prevent HIV infection.
Window Period: This is the period of time between potential exposure to an STI/HIV, and when a test will give an accurate result. In the case of HIV, following infection viral multiplication occurs which triggers the body to produce antibodies against the virus. During this time, the virus may be present but undetectable by any tests resulting in a false negative. Once these molecules have reached a sufficient level, antibodies as well as viral proteins, can then be identified through laboratory screening.
Acute HIV Infection: Following infection, the number of viral copies dramatically increases for 2-4 weeks while the body mounts an initial immune response and generates antibodies against the virus. This period is generally characterized by non-specific symptoms; however these symptoms are not always present and should not be used solely as an indicator of infection.