The role of pharmacy in HIV pre-exposure prophylaxis

Introduction

Pre-exposure prophylaxis (PrEP) is a preventive strategy involving the use of antiretroviral medications to reduce the risk of HIV infection in high-risk individuals^​1​. PrEP is taken before and after condomless sex to prevent HIV. When taken correctly, PrEP is more than 99% effective; however, it does not protect against other sexually transmitted infections (STIs)^​1​.  

In some countries, PrEP can be obtained from pharmacies, but in the UK it is provided free of charge from sexual health clinics and can be bought online^​2​. PrEP can be taken orally daily or ‘on demand’ before and after sex. Data shows that, as of October 2024, more than 86,000 people in the UK were already using PrEP^​3​. The UK has made a commitment to achieve zero HIV transmissions by 2030 and PrEP has gained recognition as an essential tool in achieving this^​4​. 

In February 2024, the Department of Health and Social Care (DHSC) published a roadmap for providing PrEP in the community, including in pharmacies^​5​. 

This article will cover groups that may benefit from PrEP, how PrEP can be initiated and managed, and the role of pharmacy in the dissemination and support of information about PrEP.

Who may benefit from PrEP?

There has been a decline in HIV incidence in recent years, particularly among gay, bisexual and other men who have sex with men (gbMSM)^​3​. The increased availability of PrEP has played a significant role in this progress; however, disparities in HIV prevention persist among different communities, with groups such as young people, ethnic minorities, heterosexual, trans and non-binary people, and people who inject drugs facing challenges in accessing and utilising PrEP^​3​.

Some of the barriers for these groups accessing PrEP is that they may not deem themselves at risk of HIV or know about the existence of PrEP. The British Association for Sexual Health and HIV (BASHH) guidelines — which were updated and out for consultation as of March 2025 — have encompassed a more inclusive eligibility criteria to ensure that PrEP reaches all at-risk populations and communities across the UK^​6​.

BASHH recommends that PrEP should be offered to people, regardless of their gender or sexual orientation, who would benefit from a reduction in HIV risk (defined as where HIV risk is likely to be in excess of the background UK population and where benefit outweighs clinical risk of PrEP), including:

• People who request PrEP;
• People at risk of HIV;
• People who, regardless of gender or sexual orientation, are likely to have condomless anal or vaginal sex with people at risk of HIV;
• People who inject drugs who might share injecting equipment^​6​.

How can conversations about PrEP be approached?

Pharmacists can play a pivotal role in identifying and engaging with these populations to promote PrEP awareness and uptake. Community pharmacies are essential in providing public health services and are increasingly involved in health promotion and prescribing roles^​7,8​. Pharmacists have unique opportunities to engage with people about PrEP by providing accurate information, addressing concerns, and offering support throughout the treatment journey. By fostering open and non-judgmental discussions, pharmacists can empower people to make informed decisions regarding PrEP (see Box).

Management of PrEP use

The following oral antiretroviral medicines are routinely available for use as PrEP:

• Tenofovir disoproxil 245mg/emtricitabine 200mg fixed-dose combination tablet^​9​
• Tenofovir alafenamide 25mg/emtricitabine 200mg fixed-dose combination tablet^​10​

Cabotegravir, a two-monthly injection, is currently being assessed for approval in the UK^​2​.

Anyone can start PrEP by taking a double dose (at least two hours before sex) and then continue taking one tablet daily thereafter. When stopping PrEP, it should be continued for at least two days after the last risk (i.e. the last sexual event where there was risk of exposure) for men and seven days after the last risk for women^​4​. 

PrEP can also be taken on-demand/on an event-based dosing (EBD) schedule. This involves taking PrEP around the time of sex, with a dosing schedule as shown in Figures 1 and 2^​2​.

Monitoring requirements

Monitoring is required before initiation and at regular intervals when taking PrEP to ensure the patient is suitable to begin PrEP and to maintain their sexual health when taking the medication^​2,6​. 

Before starting PrEP

HIV testing

It is essential to have a HIV test before starting PrEP. If someone that is unknowingly living with HIV takes PrEP, this can cause drug resistance to the antiretroviral components of PrEP, emtricitabine and tenofovir disoproxil or tenofovir alafenamide^​2,6​. 

A venous blood sample that is taken in a sexual health clinic will be a fourth-generation HIV blood test, also referred to as a HIV antigen/antibody test. This has a window period of six weeks; therefore, if someone has had a HIV risk in the past six weeks, they will then need to repeat the HIV test six weeks after starting PrEP to ensure that an early HIV infection has not been missed. This test can also be done via online home testing kits, such as those available from Sexual Health London (SHL).  

Most finger prick tests are currently third generation. This test needs two to three months to show a positive result following infection. Therefore, it is unreliable if someone has had a HIV risk in the past two to three months and a fourth-generation HIV test should be obtained^​2,6​.

Other tests

Renal function should be checked via a blood test for creatinine, ideally just before or on the day of starting PrEP^​2,6​. For useful information on how to calculate renal function, see: ‘Medication maths: estimations of kidney function’.

Other STIs should be tested for, including a blood test for syphilis and swabs +/- a urine test for chlamydia and gonorrhoea^​2,6​. 

A blood test for hepatitis B is essential. This is because tenofovir (disoproxil or alafenamide) is active against both HIV and hepatitis B. People with hepatitis B who request an interest in taking PrEP will need to take PrEP every day. They also need to ensure they are appropriately followed up with their hepatologist if and when they decide to stop taking PrEP. Stopping PrEP can lead to rapid inflammation in the liver, resistance to tenofovir and possible transmission of hepatitis B if no other prevention methods are used, such as condoms^​2,6​.

Once PrEP has been initiated

A HIV and STI screen is recommended every three months. 

For anyone having sex with gay men and other at-risk groups, a hepatitis C screening is recommended every 12 months. 

Renal function testing should be done for those taking tenofovir disoproxil containing PrEP:

• Annual eGFR testing should be conducted for people aged under 40 years with an eGFR ≥ 90mL/min/1.73m² at baseline with no risks for renal disease;
• For people either aged over 40 years with an eGFR < 90mL/min/1.73m² or with risks for renal disease, such as diabetes or hypertension, this should be conducted every 6 months^​6​.

Side effects 

Most people taking PrEP either do not experience side effects or suffer from some mild side effects that tend to lessen after the first month of use. These can include nausea, diarrhoea, bloating, insomnia and headache, and are reported by less than 1 in 10 people^​2,9,10​.

The oral formulation containing tenofovir disoproxil can occasionally cause more serious side effects that reduce kidney function, such as chronic kidney disease, and/or impact bone health, such as osteoporosis. Therefore, kidney tests are needed when using oral PrEP^​2​. 

Tenofovir alafenamide/emtricitabine is less likely to affect kidneys and bone health so it is recommended for people experiencing or at risk of poor kidney or bone health. For example, it would be recommended for people aged under 18 years, as adolescence is a critical period for bone growth, or for people with renal risk factors (e.g. high blood pressure or diabetes)^​11​.

Contraindications and interactions

PrEP only interacts with a few other medicines; however, it should be noted that tenofovir disoproxil should be used with caution with other medicines that affect the kidneys. These include some non-steroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, ibuprofen and naproxen^​9​. 

Tenofovir alafenamide can interact with tuberculosis medication, such as rifampicin and rifabutin, and anti-epileptics, such as carbamazepine, oxcarbazepine, phenobarbital and phenytoin. St John’s Wort can reduce the levels of tenofovir alafenamide^​10​. 

Both oral formulations are safe for trans and non-binary people taking hormone therapy and specific reassurance should be given that there is no expected drug–drug interactions with gender-affirming hormone therapy^​2,6​.

Contraception

It is safe to use PrEP with all hormonal contraception (ring, patch, the pill, injectable or an implant)^​2,6​. 

Pregnancy and breastfeeding

Evidence has shown that PrEP has no adverse effects in HIV-negative pregnant women^​12,13​. If planning a pregnancy and not using barrier protection or condoms, daily PrEP can protect you from HIV². PrEP could be considered as a preventive measure for HIV-negative partners in serodifferent relationships seeking to conceive, especially if the HIV-positive partner is not on suppressive antiretroviral therapy^​2​. In general, the advantages of averting HIV transmission during pregnancy far exceed any possible adverse effects on the mother or child^​6​. There is also no evidence that PrEP affects the fertility of women or men^​6​.

PrEP is considered safe for infants during breastfeeding^​14,15​. There is significant experience with the use of tenofovir disoproxil containing PrEP in breastfeeding women living with HIV, with data showing minimal concentrations of both emtricitabine and tenofovir disoproxil in breast milk^​14,15​.

Patient counselling

The following counselling points relating to sexual health should be provided during patient consultations regarding PrEP:

• Emphasise the importance of regular sexual health check-ups, especially for individuals with multiple sexual partners or high-risk behaviours. Depending on the location, this can be done through their local sexual health clinic or through online testing kits. In addition, some community pharmacies are commissioned to provide chlamydia screening and HIV testing^​16​;
• Educate patients on safe sex practices, including the consistent and correct use of condoms to reduce the risk of sexually transmitted infections and unintended pregnancies;
• Some community pharmacies across London now offer the Come Correct (C-Card) scheme, which provides free condoms, lubrication, female condoms, dental dams and sexual health information to people aged under 25 years^​17​;
• Information on other practical strategies for sexual health, such as discussing contraception options, getting vaccinated against sexually transmitted infections such as HPV, and seeking support for any concerns or issues related to sexual health;
• Some community pharmacies offer emergency contraception over the counter or via a patient group directive (PGD) or will offer routine oral contraception. For long-acting contraception, such as coils and implants, they can refer patients to sexual health clinics. 

Role of community pharmacies in expansion of PrEP 

Community pharmacies are often more accessible than sexual health clinics, especially in rural areas, and could offer a more convenient and discreet option for accessing PrEP. They are well-suited to deliver public health services and health promotion^​18​. Although PrEP is not currently available via community pharmacy, expanding PrEP to this setting could reduce barriers to access and raise awareness. PrEP could be piloted in community pharmacies in Wales from autumn 2025^​19​.

Some challenges for community pharmacies in providing PrEP include: obtaining PrEP through the same pathways as sexual health clinics; pharmacists needing to be able to arrange HIV and renal testing; and pharmacists needing to be able to refer patients who test positive for HIV to local services^​18​. It is important to also address the legal implications of community pharmacies supplying PrEP medication. In England, PrEP is commissioned by local authorities provided through level three sexual health clinics and the PrEP medication is funded by NHS England^​11​. Various cost factors must be considered, such as the expenses associated with community pharmacies offering an enhanced service, drug tariff costs and prescription charges, especially when individuals can currently access PrEP at no cost from sexual health clinics.

Conclusion 

Community pharmacies serve as accessible hubs for obtaining PrEP, offering convenience and reducing stigma compared with traditional sexual health clinics. By leveraging their expertise and resources, pharmacists can enhance PrEP accessibility and adherence within their communities. By integrating PrEP services into community pharmacy practice, healthcare professionals can contribute significantly to HIV prevention efforts and improve public health outcomes.