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Integrating PrEP

CME

Integrating PrEP in Asia

Physicians: maximum of 1.00 AMA PRA Category 1 Credit

Released: June 09, 2025

Expiration: June 08, 2026

Stephane Wen-Wei Ku
Stephane Wen-Wei Ku, MD
CME/CE Information

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Case 2: Mr. L

Moving on to the next case study, let us meet our second client, Mr. L. He is a 44-year-old single cisgender man who has sex with men. He presents at the clinic for postexposure prophylaxis (PEP) for HIV because he had condomless anal sex yesterday. He rarely uses condoms and has already had 2 courses of PEP before this encounter.

Mr. L tested negative for HIV 2 months ago and has no previous history of STIs. When asked about recreational or sexualized drug use, he said that he recently started using crystal methamphetamine during sex by both smoking and “slamming,” or intravenous injection. 

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What Would You Like to Talk About With Mr. L?

How would you approach this client? It should be clear that providing PEP for HIV and DoxyPEP for other STI prevention is urgent, especially within 72 hours of possible exposure.

Of course before prescribing PEP, it is mandatory to check Mr. L’s HIV status and perhaps screen for other STIs such as syphilis, gonorrhea, and chlamydia.

Given a repetitive and ongoing risk of exposure to HIV, it is advised to bridge to PrEP immediately upon completing 28 days of PEP. Although many people prefer event-driven PrEP in Asia, I would recommend that Mr. L take PrEP daily if he cannot anticipate when he will have sex or if he has difficulties remembering to take event-driven PrEP on time.

Discussing sexualized drug use, or chemsex, is also important to identify whether Mr. L has problematic crystal methamphetamine use or any sign of interdependence.

If the client is not ready to start treatment for crystal methamphetamine use, I would also provide harm-reduction information for intravenous drug use such as clean needle and syringe services to avoid other blood-borne infections such as hepatitis B and hepatitis C. 

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Potential for Expansion of PrEP Services: Harm Reduction

Mr. L’s case illustrates how integration of PrEP with other healthcare services could greatly benefit members of key populations.

In some countries, there are existing services for key populations, such as harm reduction with needle syringe services, STI screening and treatment, gender-affirming hormone therapy, and family planning with contraception.13

PrEP delivery can be built upon these services without too much additional effort. Vice versa, expanding PrEP by adding some, if not all of these other services can also be feasible, depending on the scale of the facilities and the available training for staff. As mentioned earlier, such integrated services are more welcomed by communities and help to increase the PrEP uptake by key populations.13 

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Potential for Expansion of PrEP Services: Harm-Reduction Strategies for Chemsex

PrEP or PEP for HIV can be an important harm-reduction strategy for people engaging in chemsex, for example. HIV prevention can be integrated into existing harm-reduction strategies to prevent acquisition of other STIs such as hepatitis B, hepatitis C, and human papillomavirus.14

Conversely, integrating harm-reduction strategies into PEP and PrEP delivery can improve access to services to avoid intoxication or even deadly overdose during chemsex, and can help minimize nonconsensual sex and intimate partner violence. All  of these aspects of harm reduction are equally important.14

In Taiwan, I have observed that more and more psychiatrists who see patients who engage in chemsex are now prescribing PrEP as harm reduction in the same clinic in an effort to provide 1-stop integrated service to the key populations. 

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Potential for Expansion of PrEP Services: STI Screening

STI screening can also be a great opportunity to initiate conversations regarding PrEP, as demonstrated by the patient from our first case who presented at the clinic for dysuria and vaginal discharge. Vice versa, STI screening can be integrated into routine lab monitoring for PrEP services as well.15,16 

That being said, the results of a recent meta-analysis found that significant gaps still exist in providing STI screening within PrEP programs, especially for low- to mid-low income countries. Standardized practice guidelines, improved staff training to build capacity for increased service, and adequate funding are all necessary for effective integration of STI screening with PrEP programs.15  

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Potential for Expansion of PrEP Services: Gender-Affirming Hormone Therapy

Providing PrEP and gender-affirming hormone therapy at the same place with peer health navigation is also an effective way to engage key populations in PrEP, as demonstrated by HPTN 091.

HPTN 091 was an international, open-label, randomized trial that enrolled more than 300 transgender women without HIV. Participants were randomized into 2 different arms with immediate or deferred intervention, consisting of PrEP provision plus colocated gender-affirming hormone therapy and peer health navigation.17

By the end of the trial, both the retention rate and rate of PrEP uptake were quite high; >80% in both arms, showing the importance of integrating and colocating gender-affirming hormone therapy and PrEP.17

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Differentiated Service Delivery Models: M-Health Interventions

Finally, I would like to conclude by stressing the importance of differentiating and simplifying PrEP delivery. This means not only customizing PrEP services according to the needs and preferences of users, but also making these services acceptable and accessible.

For example, in Malaysia, innovative mobile health (m-health) technologies are used to make PrEP accessible beyond clinical settings. In particular, the JomPrEP app is used to deliver holistic HIV prevention services, including HIV self-testing and PrEP services including HIV risk assessment; lab appointments; e-consultation; and PrEP delivery. JomPrEP even offers support for mental health and substance use.18,19

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Differentiated Service Delivery Models: Pharmacy-Based PrEP Service Delivery Model in Malaysia

Meanwhile, also in Malaysia, a pharmacy-led PrEP service delivery model was explored to increase PrEP access and uptake in the Klang Valley. This model leveraged the accessibility of community pharmacies and the expertise of highly trained community pharmacists who are often the first point of contact for health advice among people in this area.8 

With this method, pharmacists assess PrEP eligibility with a digital assessment tool and on-site HIV screening with self-test kits at the pharmacies. Eligible individuals could then initiate PrEP on the same day with an electronic PrEP prescription obtained from a physician via telemedicine.8

After implementation, the researchers found that this model was associated with high levels of acceptability in the community and high rates of initiation and retention among participants. This model demonstrates the impact and feasibility of simplified delivery of PrEP services in a nonclinical setting.8 

In all, both the JomPrEP app and this pharmacy-led service delivery model are prime examples of using differentiated service delivery models to streamline PrEP delivery and overcome access barriers.

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I am aware of strategies to integrate PrEP services for the benefit of key populations.

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