Pre-Exposure Prophylaxis for HIV Prevention.

c ase vignet tes The first patient, a 46-year-old sexually active man who has sex with men, presents for routine primary care. He lives in New York City and reports that he is in a long-term, stable, open relationship with a male partner and that he has had multiple recent sexual encounters with acquaintances. A recent HIV test was negative. He has seasonal allergies, for which he occasionally takes antihistamines, and chronic lower back pain, for which he takes nonsteroidal antiinflammatory drugs on a regular basis. Otherwise he takes no medications and has no known allergies to medications. He had syphilis 10 years earlier for which he was successfully treated. His physical examination is notable only for the fact that he is uncircumcised. You review HIV prevention strategies in detail with him, including the potential benefits of circumcision and of the use of condoms. He has been reading information on the Internet, including information about preexposure prophylaxis (PrEP), and asks whether he should be receiving this therapy. The second patient, an 18-year-old heterosexual woman in South Africa who has recently become sexually active, presents for voluntary HIV testing. She does not know the HIV status of her male partners. She reports no medical problems, is taking no medications, and has no known allergies to medications. She reports that her older sister recently received a diagnosis of HIV infection. Her physical examination is unremarkable. Testing for sexually transmitted infections is performed. A pregnancy test is negative. She would like to initiate birth control and elects to start taking oral contraceptive pills. She returns to the clinic the following week and is informed that all the tests for sexually transmitted infections, including the HIV test, were negative. She thinks that she had received the hepatitis B vaccination series. She is negative for hepatitis B surface antigen. She is given extensive HIV counseling, and the various HIV prevention strategies are reviewed in detail.