Providers

What happens if your client misses a PrEP pill?

What happens if your client misses a PrEP pill?

If your client misses a pill, they should take it as soon as they remember, and continue to take it daily as before.

PrEP requires strict adherence to daily medication and regular HIV testing. Where possible, it should be used together with other HIV prevention methods.

If it is used properly, PrEP will play a role in helping to reduce the number of new HIV infections in South Africa.

Discussing adherence

Discussing adherence

“Pill taking isn’t easy and takes some practice, especially if you aren’t used to taking pills.”

“It’s okay to not be perfect at taking your pills; it takes time. But remember in order for PrEP to work, you have to take your pills regularly.”

“I’m here to help by working with you to figure out a way to make taking your pills easier, so that you get the most protection you can.”

Considering PrEP

Considering PrEP

“PrEP is a great way to prevent HIV, but it isn’t for everyone.”

“Taking a pill every day for ongoing protection from HIV might not be for everybody, but PrEP is an excellent and much-needed extra prevention method for people at high risk of getting HIV.”

“The use of PrEP is supported by South African medical experts, the South African government, and many international experts.”

“You’ve decided to use PrEP as a way to protect yourself and that’s great.”

“If you start PrEP, you do not have to take it for the rest of your life.”

Remember! Be honest, direct and non-confrontational

Remember! Be honest, direct and non-confrontational

Supporting pill-taking should be honest, direct and non-confrontational.

Steps to follow:

  1. Assess how pill taking is going for PrEP client
  2. Positively affirm client to support provider/client relationship
  3. Identify a motivator to support effective pill taking
  4. Provide PrEP education regarding effective use and effectiveness of PrEP
  5. Identify barriers to effective use
  6. Provide realistic strategies to address barriers
  7. Discuss use of other HIV prevention measures that are relevant to situation
  8. Ensure client leaves with realistic and achievable plan to increase or sustain use
Adherence is critical to providing protection against HIV

Adherence is critical to providing protection against HIV

Adherence means taking the PrEP pill every day.

Suggest methods to remind the client to take the pill every day.

For example:

  • Take the pill at the same time every day
  • Incorporate it into your daily activities, like part of your morning routine or when a favourite TV show comes on
  • Set a phone alarm
  • Use daily pillboxes

Daily PrEP can be taken with alcohol, drugs or contraception. It does not react negatively with any normal day to day activity.

Discuss what to do if a pill is missed – take it as soon as client remembers.

Checklist: Follow-up Counselling

Checklist: Follow-up Counselling

Follow-up sessions will most likely be brief. It is critical to review adherence during these discussions and re-evaluate the client’s risk profile if he or she has experienced lifestyle changes. Please ensure you use your organisation’s available counselling tools for each of these topics.

Re-assess the client’s risk profile

Discuss any lifestyle changes that may affect the suitability of PrEP use.

Combination prevention

Touch base with the client’s sexual health plan and make sure they have access to other prevention resources, as appropriate.

STIs

PrEP does not protect against STIs. Regular testing for STIs is encouraged, regardless of PrEP use. IMPORTANT: If your client presents with an STI, they will need additional counselling.

Contraception / Fertility goals

PrEP is not a contraceptive. PrEP is safe to use with all contraceptive methods. Consult with a physician to provide guidance on how to proceed if the client becomes pregnant.

Adherence (daily)*

For PrEP to be effective, the pill must be taken every day. Adherence counselling is critical for full HIV protection. *More detail is provided in the Adherence section that follows.

Side effects

Touch base about the client’s experience with side effects.

REMEMBER: If side effects are serious, please involve a doctor with your client’s care.

Intimate partner violence (IPV)

People who have abusive or controlling partners may find it more difficult to take care of their sexual health and to adhere to PrEP. Ask about the client’s relationships, and for clients experiencing abuse, provide counselling and referrals, when possible.

Talking to your partner, family, friends, etc.

Deciding whether to tell anyone about your PrEP use is a completely personal decision. Some people find it helpful to tell friends or family for support and to provide reminders to take the pill daily. Discuss with the client whether and how they would like to discuss PrEP with loved ones and how to overcome any potential barriers to gaining their support.

Visit schedule

Explain the visit schedule for PrEP use. The client must return for follow-up visits at the first month, and then every three months. They must also return to the clinic monthly to pick up their pills.

Checklist: Counselling prior to PrEP initiation

Checklist: Counselling prior to PrEP initiation

This is a list of important topics to discuss with the client when explaining PrEP for the first time and deciding whether it might be right for him or her. It is not comprehensive. Please ensure you use your organisation’s available counselling tools for each of these topics.

What to discuss:

Assess the client’s risk profile

How to discuss it:

Develop a clear picture of the client’s risk profile and lifestyle; make sure they understand how their lifestyle impacts their risk profile. IMPORTANT: use your organisation’s risk assessment tools.

What to discuss:

Combination prevention

How to discuss it:

Taken daily, PrEP is an additional prevention option. It should be used in combination with other prevention tools, like condoms, PEP, healthy lifestyles, treatment for STIs, male medical circumcision, and ART for partners living with HIV. REMEMBER: counselling should highlight that ideally PrEP should be used with condoms.

What to discuss:

Condom negotiation

How to discuss it:

Some clients, may not be able to enforce condom use. Provide guidance on how to safely advocate for condom use by the partner. IMPORTANT: does your organisation have a tool that can help you?

What to discuss:

STIs

How to discuss it:

PrEP does not protect against STIs. Regular testing for STIs is encouraged, regardless of PrEP use. REMEMBER: STIs may increase the risk of HIV acquisition.

What to discuss:

Contraception / Fertility goals

How to discuss it:

PrEP is not a contraceptive. PrEP is safe to use with all contraceptive methods. Consult with a physician to provide guidance on how to proceed if the client becomes pregnant.

What to discuss:

Adherence (daily)*

How to discuss it:

For PrEP to be effective, the pill must be taken every day. Adherence counselling is critical for full HIV protection. *More detail is provided in the Adherence section that follows.

What to discuss:

Side effects

How to discuss it:

Some people get mild side effects when they start PrEP, but they generally go away after a few weeks. The most common side effects include: nausea, headache, tiredness, diarrhea, depression, abnormal dreams, vomiting, rash, problems sleeping, and changes in appetite.

What to discuss:

Intimate partner violence (IPV)

How to discuss it:

People who have abusive or controlling partners may find it more difficult to take care of their sexual health and to adhere to PrEP. Ask about the client’s relationships, and for clients experiencing abuse, provide counselling and referrals, when possible.

What to discuss:

Talking to your partner, family, friends, etc.

How to discuss it:

Deciding whether to tell anyone about your PrEP use is a completely personal decision. Some people find it helpful to tell friends or family for support and to provide reminders to take the pill daily. Discuss with the client whether and how they would like to discuss PrEP with loved ones and how to overcome any potential barriers to gaining their support.

What to discuss:

Visit schedule

How to discuss it:

Explain the visit schedule for PrEP use. The client must return for follow-up visits at the first month, and then every three months. They must also return to the clinic monthly to pick up their pills.

Counselling should be:

Counselling should be:

  • Sensitive, inclusive, and non-judgmental
    Recognize that behaviour change is difficult and human beings are not perfect
  • Presented as a personal choice
    Counselling should support the client in making a personal choice based on their needs and desires.
  • Problem solve and foster motivation
    Offer choices and tangible solutions; identify small wins and achievable next steps in reducing risk.
  • Client-driven and based on their needs, resources, and preferences
    Counselling should be interactive and tailored to the client’s specific needs and lifestyle.
  • Brief
    10-15 minute check-ins about experience with PrEP and sexual health protection plans are most effective; longer (~30 minute) sessions may be necessary at the first PrEP consultation or if specific issues arise.