HIV Testing Before and During PrEP: Getting It Right

This episode, "HIV Testing Before and During PrEP: Getting It Right," features the faculty walking through baseline and ongoing HIV testing for patients starting or continuing PrEP.

Dr. Cocohoba asks Dr. Urbina to address baseline HIV testing, which can intimidate clinicians new to PrEP. Dr. Urbina explains that options vary by setting. Rapid point-of-care assays allow same-day results, while lab-based fourth-generation tests can detect infection around day 18. Because Mount Sinai takes a conservative approach to ruling out acute infection, his team pairs an HIV RNA viral load test with a lab-based fourth-generation test. The viral load test can detect virus by about day 10. Once both are negative, they start PrEP with confidence. He adds that in other settings a rapid test can support same-day oral PrEP starts. A careful history remains critical, including febrile illness suggestive of acute HIV and any recent exposures. Dr. Cocohoba confirms that UCSF uses a similar approach, while noting that clinicians must adapt to the resources available to them.

Dr. Urbina then explains why ongoing monitoring matters. If someone acquires HIV, perhaps after missing an injection, continuing PrEP alone would leave ongoing viral replication under a single agent. That raises the risk of resistance, so such patients need fully active antiretroviral therapy instead. At follow-up visits, his clinic runs a rapid test, draws a lab-based fourth-generation test, and injects the same day if the rapid result is negative. Dr. Cocohoba reinforces that PrEP is prevention, and partial treatment must be avoided.

Dr. Cocohoba outlines the pharmacist's role across this process. Pharmacists can remind patients picking up refills to complete HIV and STI testing, and some administer tests on site or order them where authority allows. Some community pharmacies now perform point-of-care fingerstick testing in a counseling room or small private space. She cites a Virginia demonstration project that established sustainable pharmacy-based testing in high-need areas.

In "PrEP Deserts: Why HIV Prevention Still Misses Those at Risk," the faculty will examine why PrEP uptake still lags where HIV is growing fastest, and how perceived risk, stigma, and geography keep people from care.