Who is HIV PrEP for? ​

• Aged 16 or over​
• Tested HIV negative​
• Able to attend the clinic for regular appointments including for monitoring, sexual health care and support and to collect prescriptions​
• Willing to stop NHS-funded PrEP if there is no longer a benefit​
• Resident in Scotland​​

In 2017, the following PrEP eligibility criteria were implemented:​

• Current sexual health partners, irrespective of gender, of people who are living with HIV and with a detectable viral load​
• GBMSM and transgender women with a documented bacterial rectal STI in the last 12 months​
• GBMSM and transgender women reporting condomless penetrative anal sex with two or more partners in the last 12 months, and likely to do so again in the next three months​
• Individuals, irrespective of gender, at equivalent high risk of HIV acquisition, as agreed with another specialist clinician​

This has now been superseded by new guidance on who can benefit from PrEP¹¹​.

Focussing on eligibility criteria excludes individuals who may benefit from HIV risk reduction, including those who are at risk due to a partner's sexual behaviour, or those who do not initially report risk​.​

Such criteria are often determined by clinical trial design and do not represent an evidence base for the limits of risk-benefit​.​

While defining these limits helps to identify people who would definitely benefit from PrEP, caution should be exercised to ensure that people are not excluded  ​

• People who request PrEP^12-13* ​
• People who would benefit from a reduction in HIV risk​
• People who, regardless of gender, might have condomless anal or vaginal sex with people at risk of HIV​
• People who inject drugs who might share injecting equipment​

The decision to offer or initiate PrEP is informed by sexual and/or drug use history and risks that have occurred in the preceding months or likely to occur in the following months​.

Evidence of benefit is greatest for men who have sex with men, and trans women who have sex with men who report receptive condomless anal sex and people who report condomless vaginal or anal sex with an HIV positive partner without viral suppression​.

People in one or more of the following groups are also likely to benefit from PrEP: ​

• people who have sexualised drug use (chemsex)
• people who have condomless anal or vaginal sex with partner(s) from high prevalence populations such as partners who are men who have sex with men or people from high HIV prevalence countries​
• people who inject drugs who share injecting equipment or who have multiple risks including through sex​
• people involved in transactional sex 

*except where individual risk of HIV infection is low or clinical risk of PrEP outweighs benefit

With the initial focus of trials, eligibility criteria, guidelines and public health awareness campaigns was the GBMSM community, there are many other groups that would benefit from PrEP which services have not been designed to encourage engagement from underserved groups. ​

​Poor and uneven awareness has been reported amongst:​

• racially minoritised groups ​
• trans and non-binary communities​
• heterosexual women and men ​
• younger gay and bisexual men

• Population level indicators, for example demography​
• Behavioural and personal indicators, for example condomless sex, travel, injecting drug use ​
• Clinical indicators (particularly recent) including known sexually transmitted infection, HCV infection*​
• Drug use​
• Reduced sexual health autonomy​
• Psychological indicators, such as anxiety related to HIV acquisition**​

*Wherever clinicians or other health workers are reviewing the risk of sexually transmitted infection, including HIV, with a patient, the suitability for PrEP should be considered. These situations include when an HIV test or other STI tests are offered or the results reviewed, when an STI is diagnosed or treated, when partner notification occurs and when PEPSE is initiated or reviewed.​

**People with anxiety about HIV transmission that seems greater than their objective risk may request or consider PrEP. Although people who take PrEP gain significant relief of anxiety and psychological distress, recommendations on PrEP benefit are based on transmission risk. Referral to psychological services should be considered for people whose anxiety is disproportionate to their reported risk of HIV acquisition. However, some people may not feel comfortable reporting their risk of HIV acquisition and occasionally it may be appropriate to provide PrEP when a person requests if even if reported risk appears low. ​

​

HIV PrEP is not required if:​

• HIV positive or suspected to be HIV positive​
• For sex with a partner living with HIV with undetectable viral load for over 6 months (Undetectable = Untransmittable, U=U)

​Some patients will require specialist medical input when commencing PrEP e.g. patients with renal or bone density comorbidities or people with chronic hepatitis B infection​

If under 18 years at initiation, tenofovir alafenamide/emtricitabine (Descovy) is recommended until 20 years of age​