Oral HIV PrEP: hospitalist-led inpatient initiation after HM17

Hospital Medicine 2017, organised by the Society of Hospital Medicine, ran from 1–4 May at Mandalay Bay Resort and Casino in Las Vegas. Its programme brought hospitalists together for research, clinical updates, practical workshops and continuing medical education credits. Oral HIV pre-exposure prophylaxis provided a timely clinical question: should prevention begin before discharge rather than waiting for a separate sexual health appointment?

This review translates the HM17 focus for Australian hospitalists, covering eligibility, baseline assessment, prescribing, linkage and follow-up. It treats PrEP as ongoing prevention for HIV-negative people, not emergency treatment after exposure, and stresses that inpatient initiation succeeds only when discharge and ongoing care are arranged together.

Why the hospital encounter matters

In 2017, fixed-dose tenofovir disoproxil fumarate with emtricitabine was moving from a specialist HIV option into mainstream prevention. For hospitalists, its value was not simply a daily tablet. It was the ability to identify unmet prevention needs during an admission and connect the patient to a sustainable pathway.

Hospitalists may encounter people who are already comfortable discussing sexual health but have not been offered PrEP, or who know about it but face cost, stigma, disability, travel or clinic-access barriers. A private, non-judgemental question about whether the patient wants an HIV prevention plan is more useful than assumptions about identity or behaviour.

The conference education resources place this issue within a wider meeting about improving hospital practice. The lasting lesson was that prevention need not wait for an HIV clinic: ordinary inpatient care can provide the trigger for assessment, treatment and reliable follow-up.

Assessing eligibility and baseline safety

PrEP should be considered for an HIV-negative person who reports ongoing exposure risk and can use the medicine consistently enough to benefit. Confirm HIV status using the current Australian testing approach; a negative result from an acute-care assay alone may not exclude recent infection. Document risk without unnecessarily recording sexual orientation, and obtain consent using a qualified interpreter when needed.

Baseline assessment also includes renal function, hepatitis B and other clinically relevant viral hepatitis, pregnancy where relevant, and testing for bacterial and other STIs according to local guidance. TDF/FTC is active against hepatitis B, so hepatitis B status affects stopping advice and referral. Check medicines that may affect renal function or increase toxicity, and review pregnancy, contraception and plans for pregnancy with the patient.

A recent high-risk exposure requires a different pathway. HIV post-exposure prophylaxis is time-limited, uses multiple medicines and should be assessed promptly, ideally within two hours and no later than 72 hours after exposure. PrEP does not replace PEP. If baseline HIV testing suggests established infection, do not start PrEP alone; arrange urgent HIV medicine assessment.

Building a safe initiation and discharge pathway

A documented order helps teams act consistently: indication, HIV test result, renal and hepatitis B review, counselling, the agreed regimen, follow-up interval and named clinician. Ask about swallowing, vomiting, interactions and the patient’s usual routine. Where there is uncertainty about adherence or capacity to make an informed decision, involve the HIV service before prescribing rather than deferring without a plan.

The regimen should follow current Australian Product Information and the Australasian HIV Management Guidelines rather than assumptions from 2017. Pharmacy and medical teams should reconcile the hospital medicines list and any external PrEP prescription, preventing duplicate therapy. Record the patient’s preferred pharmacy and supply route because inpatient administration, a hospital discharge medicine and a PBS prescription may otherwise create gaps or duplication.

Discharge is a safety checkpoint, not a handover of responsibility. Confirm the first supply, access to ongoing repeats, a follow-up appointment and contact details for missed doses or adverse effects. Give a written schedule in plain English: one fixed-dose tablet once daily, no dose doubling and advice consistent with current Product Information. Condoms, vaccination and STI prevention remain part of the plan, not substitutes for PrEP.

Adapting the approach for Australia

Australian prescribing sits within the Therapeutic Goods Administration and the Pharmaceutical Benefits Scheme. In 2017, PBS access to PrEP was narrower than the broader eligibility later introduced; current hospital policy must therefore use present-day PBS criteria and local discharge arrangements. Specialist sexual health services in Melbourne and Sydney support referral, while public HIV services in Brisbane, Perth, Adelaide and Darwin provide important regional networks.

State and tertiary hospitals differ in whether they can supply a first pack on discharge, claim PBS subsidy for an outpatient prescription or require a community pharmacy to dispense it. A standard plan should name the authorised prescriber, accessible dispensing route and contingency if the preferred pharmacy is closed. Medicare, public outpatient services and telehealth can support follow-up, but referral letters alone do not ensure continuity.

Access also requires cultural and geographic fit. In Aboriginal and Torres Strait Islander communities, including remote settings in central Australia and northern Western Australia, privacy and cultural safety should be designed with local services rather than assumed. Some patients need Aboriginal health workers, an Aboriginal Medical Service, sexual health staff or telehealth follow-up. Where English is a second language, counselling and consent materials must be available in the patient’s preferred language.

Follow-up, adherence and prevention beyond discharge

Follow-up should be booked before discharge through a service able to test, review adverse effects and continue prescribing. HIV testing is commonly repeated about every three months, while renal function and other investigations follow current clinical guidance and the medicine’s Product Information. Re-test for STIs as indicated, review relevant risk factors sensitively and ask whether medication cost, stigma or housing instability has disrupted supply.

Adherence conversations should be practical. Simplify the routine, ask what has made doses difficult and involve a pharmacist or case worker when refills are the barrier. Do not advise doubling after missed doses; follow current Product Information. Reassess pregnancy intentions, medication interactions, hepatitis B status and the ongoing need for PrEP at each meaningful review.

A missed appointment is a trigger for support, not a reason to assume permanent disengagement. Send an accessible reminder, allow re-entry without punishment and coordinate across sexual health, HIV, primary care and pharmacy services. With regular testing and reliable medicine access, continued PrEP can reduce HIV acquisition while preserving routine prevention of STIs and viral hepatitis.

Evidence, clinical distinctions and lasting lessons

The evidence case for oral TDF/FTC was stronger than evidence specifically testing inpatient initiation. Trials established biological efficacy, while service studies examined uptake and retention. Melbourne’s IPEX study showed that trusted clinicians offering PrEP in sexual health settings increased initiation, but it did not establish that every hospital pathway would achieve the same result. Implementation still depends on consent, pharmacy access and reliable follow-up.

The most important safety distinction can be seen by comparing prevention, post-exposure care and HIV treatment. Clinical staff should recognise the purpose, regimen and urgency of each pathway before writing an order.

PrEP complements rather than replaces PEP, condoms or HIV treatment. A hospital prescription can close a prevention gap, but only if the medication label, supply and next appointment agree on what happens after discharge.

Building a hospital PrEP initiation pathway

A hospital pathway should be owned jointly by HIV medicine, pharmacy, sexual health, nursing and primary-care representatives, with input from Aboriginal health services and affected communities. Governance matters because clinical appropriateness alone does not ensure access. The service should define who may initiate, how medicines leave the hospital, where results return and who acts when a patient does not attend.

The following measures create a dependable minimum standard.

• Confirm HIV-negative status and document an ongoing prevention indication before prescribing.
• Use one order set linking baseline blood tests, counselling, contraindication checks and discharge tasks.
• Name the prescriber, dispensing pathway and follow-up service, including arrangements after weekends and public holidays.
• Supply an accessible medication schedule, missed-dose advice and key contact numbers in the patient’s preferred language.
• Book the first review before discharge and provide a rapid route back for adverse effects or supply problems.
• Audit initiation, follow-up attendance, HIV testing, renal assessment and patient-reported access without recording unnecessary identity data.

The pathway should first be tested against one realistic case: an HIV-negative patient admitted for an unrelated condition who requests PrEP and can take an oral medicine. Pharmacy, HIV medicine and community follow-up should confirm that baseline results, supply and the first appointment work across organisational boundaries.

The next concrete step is a one-page PrEP initiation pathway approved by the hospital’s HIV and pharmacy leads before the first inpatient prescription.