Counselling Guidelines

  • navigate_next   Why is counselling about PrEP so important?
  • navigate_next   What is PrEP?
  • navigate_next   How long does it take for PrEP to work?
  • navigate_next   PrEP does not
  • navigate_next   How often should PrEP be taken?
  • navigate_next   Counselling should be:

Counselling Checklists

  • navigate_next   Checklist: Counselling prior to PrEP initiation
  • navigate_next   Checklist: Follow-up counselling

Adherence counselling

  • navigate_next   Adherence is critical to providing protection against HIV.
  • navigate_next   Remember! Be honest, direct and non-confrontational

Supportive counselling messages

  • navigate_next   Examining risk profile
  • navigate_next   Considering PrEP
  • navigate_next   Combination prevention
  • navigate_next   Discussing adherence

Quick Answers: Reference for FAQs during Counselling

  • navigate_next   What is PrEP?
  • navigate_next   PrEP is the use of anti-HIV medication.
  • navigate_next   Does PrEP provide other protection?
  • navigate_next   What is the difference between PrEP, PEP, and ART?

Drug interactions

  • navigate_next   How well does PrEP work?
  • navigate_next   How long does it take for PrEP to work?
  • navigate_next   Is PrEP Safe?
  • navigate_next   What happens if you take PrEP and you are HIV-positive?
  • navigate_next   Does PrEP have side effects?
  • navigate_next   Can a person get HIV from taking PrEP?
  • navigate_next   If a person is taking PrEP, should they stop using condoms when having....
  • navigate_next   If someone is on PrEP, do they have to take it for the....

PrEP Adherence

  • navigate_next   What happens if your client misses a PrEP pill?
  • navigate_next   When and how can your client stop taking PrEP?
  • navigate_next   Can PrEP be taken for one night only?

PrEP and Pregnancy

  • navigate_next   Can PrEP be taken with contraception?
  • navigate_next   What must your client do if she wants to become pregnant while taking....
  • navigate_next   Does PrEP Prevent STI's or Pregnancy?
  • navigate_next   Starting PrEP
  • navigate_next   NO EXCUSES! PrEP should be used with other HIV prevention methods.

Drug resistance fears

  • navigate_next   If a client becomes HIV positive while on PrEP, will they be resistant....
  • navigate_next   Where is PrEP available?

PrEP tools

  • navigate_next   PrEP IEC Materials - MSM Audience – isiZulu
  • navigate_next   PrEP IEC Materials - MSM Audience – English
  • navigate_next   PrEP Job aids
  • navigate_next   PrEP IEC Materials – isiZulu
  • navigate_next   PrEP IEC Materials – English

RESOURCES

Why is counselling about PrEP so important?

HIV-negative people interested in PrEP should receive counselling prior to PrEP initiation and at follow-up visits while they are actively taking PrEP.

The information you will find here, is a quick reference guide to support consistent counselling efforts and provide helpful reminders for important topics to cover. It is a supplement for existing counselling practice and guidelines, not a comprehensive replacement.

What is PrEP?

PrEP = NEW + SAFE + HIV Prevention Method

PrEP is a new and safe method for HIV-negative people to reduce their risk of becoming infected. It is a pill that has 2 anti-HIV medicines: 200 mg of emtricitabine and 300 mg of tenofovir.

HIV-negative people who take PrEP every day can lower their risk of HIV by more than 90 percent.

PrEP is the use of an ART medication for HIV negative people for HIV Prevention.

How long does it take for PrEP to work?

After taking oral PrEP for 7 days people are fully protected, but they must continue to take it daily to remain protected.

PrEP is an extra HIV prevention option and where possible, should be used in combination with other prevention methods which include:

  • Condoms
  • Counselling
  • Medical male circumcision
  • Healthy lifestyles
  • PrEP
  • PEP
  • ART for partners living with HIV
  • Treatment for STIs

These methods can be used together according to individual needs and circumstances, to provide a combination approach to preventing HIV infection.

PrEP does not

  • PrEP does not provide immediate protection—it must be taken daily for 7 days before it offers full protection. It should continue to be taken daily.
  • PrEP does not prevent any other sexually transmitted infections or pregnancy.
  • PrEP does not protect someone from HIV after exposure.

How often should PrEP be taken?

One PrEP pill should be taken once a day with or without food. It helps to take the pill at the same time each day so that they do not forget.

Checklist: Counselling prior to PrEP initiation

This is a list of important topics to discuss with the client when explaining PrEP for the first time and deciding whether it might be right for him or her. It is not comprehensive. Please ensure you use your organisation’s available counselling tools for each of these topics.

What to discuss:

How to discuss it:

Assess the client’s risk profile

Develop a clear picture of the client’s risk profile and lifestyle; make sure they understand how their lifestyle impacts their risk profile. IMPORTANT: use your organisation’s risk assessment tools.

Combination prevention

Taken daily, PrEP is an additional prevention option. It should be used in combination with other prevention tools, like condoms, PEP, healthy lifestyles, treatment for STIs, male medical circumcision, and ART for partners living with HIV. REMEMBER: counselling should highlight that ideally PrEP should be used with condoms.

Condom negotiation

Some clients, may not be able to enforce condom use. Provide guidance on how to safely advocate for condom use by the partner. IMPORTANT: does your organisation have a tool that can help you?

STIs

PrEP does not protect against STIs. Regular testing for STIs is encouraged, regardless of PrEP use. REMEMBER: STIs may increase the risk of HIV acquisition.

Contraception / Fertility goals

PrEP is not a contraceptive. PrEP is safe to use with all contraceptive methods. Consult with a physician to provide guidance on how to proceed if the client becomes pregnant.

Adherence (daily)*

For PrEP to be effective, the pill must be taken every day. Adherence counselling is critical for full HIV protection. *More detail is provided in the Adherence section that follows.

Side effects

Some people get mild side effects when they start PrEP, but they generally go away after a few weeks. The most common side effects include: nausea, headache, tiredness, diarrhea, depression, abnormal dreams, vomiting, rash, problems sleeping, and changes in appetite.

Intimate partner violence (IPV)

People who have abusive or controlling partners may find it more difficult to take care of their sexual health and to adhere to PrEP. Ask about the client’s relationships, and for clients experiencing abuse, provide counselling and referrals, when possible.

Talking to your partner, family, friends, etc.

Deciding whether to tell anyone about your PrEP use is a completely personal decision. Some people find it helpful to tell friends or family for support and to provide reminders to take the pill daily. Discuss with the client whether and how they would like to discuss PrEP with loved ones and how to overcome any potential barriers to gaining their support.

Visit schedule

Explain the visit schedule for PrEP use. The client must return for follow-up visits at the first month, and then every three months. They must also return to the clinic monthly to pick up their pills.

 

Adherence is critical to providing protection against HIV.

Adherence means taking the PrEP pill every day.

Suggest methods to remind the client to take the pill every day.

For example:

  • Take the pill at the same time every day
  • Incorporate it into your daily activities, like part of your morning routine or when a favourite TV show comes on
  • Set a phone alarm
  • Use daily pillboxes

Daily PrEP can be taken with alcohol, drugs or contraception. It does not react negatively with any normal day to day activity.

Discuss what to do if a pill is missed – take it as soon as client remembers.

Remember! Be honest, direct and non-confrontational

Supporting pill-taking should be honest, direct and non-confrontational.

Steps to follow:

  1. Assess how pill taking is going for PrEP client
  2. Positively affirm client to support provider/client relationship
  3. Identify a motivator to support effective pill taking
  4. Provide PrEP education regarding effective use and effectiveness of PrEP
  5. Identify barriers to effective use
  6. Provide realistic strategies to address barriers
  7. Discuss use of other HIV prevention measures that are relevant to situation
  8. Ensure client leaves with realistic and achievable plan to increase or sustain use

Examining risk profile

“Let’s look at your risk and options to prevent HIV.”

“Let’s talk about how PrEP fits into your risk reduction efforts.”

Considering PrEP

“PrEP is a great way to prevent HIV, but it isn’t for everyone.”

“Taking a pill every day for ongoing protection from HIV might not be for everybody, but PrEP is an excellent and much-needed extra prevention method for people at high risk of getting HIV.”

“The use of PrEP is supported by South African medical experts, the South African government, and many international experts.” 

“You’ve decided to use PrEP as a way to protect yourself and that’s great.”

“If you start PrEP, you do not have to take it for the rest of your life.”

Combination prevention

“PrEP is a great way to prevent HIV, but it doesn’t protect against other STIs or prevent pregnancy.”

“Using condoms and PrEP together will give you the best level of protection from both HIV and other STIs.”

Discussing adherence

“Pill taking isn’t easy and takes some practice, especially if you aren’t used to taking pills.”

“It’s okay to not be perfect at taking your pills; it takes time. But remember in order for PrEP to work, you have to take your pills regularly.”

“I’m here to help by working with you to figure out a way to make taking your pills easier, so that you get the most protection you can.”

What is PrEP?

PrEP is a new and safe HIV prevention method for HIV-negative people to reduce the risk of becoming infected.

PrEP is the use of anti-HIV medication.

PrEP is the use of anti-HIV medication that keeps HIV-negative people from getting HIV

Pre – before
Exposure – coming into contact with HIV
Prophylaxis – a medicine to prevent infection

Does PrEP provide other protection?

No. It only protects against HIV infection.

PrEP does not protect against pregnancy or other sexually transmitted infections (STIs).

What is the difference between PrEP, PEP, and ART?

All three contain antiretroviral medicines in different combination for different purposes:

PrEP is a pill that has 2 anti-HIV medicines taken daily to prevent HIV for HIV-negative people. PrEP is taken before you think you might be exposed to HIV.

PrEP is taken within 72 hours after exposure to HIV (e.g. after rape) for 28 days to prevent HIV. PEP is taken after you think you have been exposed to HIV.

ART is a 3-medicine treatment for HIV-positive people that reduces the levels of HIV in a person’s body. ART helps the body stay strong and helps it fight off infections and other illnesses.

How well does PrEP work?

HIV-negative people who take PrEP every day can lower their risk of HIV by more than 90%.

How long does it take for PrEP to work?

After taking oral PrEP for 7 days people are fully protected from HIV. But they must continue to take it daily to remain protected.

People need to take it once a day at more or less the same time. They can take it within a few hours of their normal time - as long as they only take one pill a day.

 

Is PrEP Safe?

PrEP has been shown to be very safe.

PrEP is also safe with alcohol and drugs, as well as contraceptives and other medicine.

What happens if you take PrEP and you are HIV-positive?

PrEP should not be used as HIV treatment. HIV-positive people need a combination of three ARVs for treatment, given by the healthcare provider, according to their needs.

Does PrEP have side effects?

Some people may experience mild side effects when they start PrEP.

The most common side effects include:

  • Nausea
  • Headache
  • Tiredness
  • Diarrhoea
  • Depression
  • Abnormal dreams
  • Vomiting
  • Rash
  • Problems sleeping
  • Changes in appetite

In most people, these side effects go away after a few weeks.

Can a person get HIV from taking PrEP?

No, a oerson cannot get HIV from PrEP. The medications in PrEP work to prevent HIV.

If a person is taking PrEP, should they stop using condoms when having sex?

PrEP is an extra HIV prevention option and where possible, should be used in combination with condoms.

Using condoms is still the best way to prevent HIV infection. Condoms protect against STIs and pregnancy when used correctly and consistently.

If someone is on PrEP, do they have to take it for the rest of their life?

No. It is important that they take PrEP daily while at risk of getting HIV.

When they feel that they are no longer at risk they can talk to their healthcare provider about stopping PrEP.

What happens if your client misses a PrEP pill?

If your client misses a pill, they should take it as soon as they remember, and continue to take it daily as before.

PrEP requires strict adherence to daily medication and regular HIV testing. Where possible, it should be used together with other HIV prevention methods.

If it is used properly, PrEP will play a role in helping to reduce the number of new HIV infections in South Africa.

When and how can your client stop taking PrEP?

If your client decides that they no longer wish to take PrEP, they should discuss stopping with a healthcare provider. They will get information for how long after they should continue to make sure they are properly protected.

Can PrEP be taken for one night only?

No. Your client needs to take the PrEP once a day for at least 7 days before you are fully protected.

Can PrEP be taken with contraception?

Yes, PrEP can be taken with any kind of contraception.

What must your client do if she wants to become pregnant while taking PrEP?

She must inform her clinician and together they will discuss how to proceed.

Does PrEP Prevent STI's or Pregnancy?

No. PrEP does not prevent STIs or pregnancy.

PrEP works when used together with other effective HIV prevention methods.

Starting PrEP

First visit: HIV and blood test screening and get a month's supply of PrEP

One month visit: HIV and blood test screening Get your 3-month prescription and collect your pills every month

Monthly visit: Use the prescription to collect pills every month at your clinic

Every three months: Every 3 months, return for an HIV test and a new 3-month prescription for PrEP

NO EXCUSES! PrEP should be used with other HIV prevention methods.

PrEP means taking a pill every day and going for regular HIV testing, NO EXCUSES!

PrEP should be used with other HIV prevention methods.

If a client becomes HIV positive while on PrEP, will they be resistant to ARVs?

If your client is on PrEP and they still get HIV their health care provider will do some tests to determine why they seroconverted. It does not necessarily mean that they will be resistant to ARVs (ex: window period, low adherence, infected with TDF resistant virus, etc).

Where is PrEP available?

Currently in South Africa, PrEP is being provided through a limited number of service delivery sites. Use the PrEP finder search for the nearest PrEP clinic.

Checklist: Follow-up counselling

Follow-up sessions will most likely be brief. It is critical to review adherence during these discussions and re-evaluate the client’s risk profile if he or she has experienced lifestyle changes. Please ensure you use your organisation’s available counselling tools for each of these topics.

Re-assess the client’s risk profile

Discuss any lifestyle changes that may affect the suitability of PrEP use.

Combination prevention

Touch base with the client’s sexual health plan and make sure they have access to other prevention resources, as appropriate.

STIs

PrEP does not protect against STIs. Regular testing for STIs is encouraged, regardless of PrEP use. IMPORTANT: If your client presents with an STI, they will need additional counselling.

Contraception / Fertility goals

PrEP is not a contraceptive. PrEP is safe to use with all contraceptive methods. Consult with a physician to provide guidance on how to proceed if the client becomes pregnant.

Adherence (daily)*

For PrEP to be effective, the pill must be taken every day. Adherence counselling is critical for full HIV protection. *More detail is provided in the Adherence section that follows.

Side effects

Touch base about the client’s experience with side effects.

REMEMBER: If side effects are serious, please involve a doctor with your client’s care.

Intimate partner violence (IPV)

People who have abusive or controlling partners may find it more difficult to take care of their sexual health and to adhere to PrEP. Ask about the client’s relationships, and for clients experiencing abuse, provide counselling and referrals, when possible.

Talking to your partner, family, friends, etc.

Deciding whether to tell anyone about your PrEP use is a completely personal decision. Some people find it helpful to tell friends or family for support and to provide reminders to take the pill daily. Discuss with the client whether and how they would like to discuss PrEP with loved ones and how to overcome any potential barriers to gaining their support.

Visit schedule

Explain the visit schedule for PrEP use. The client must return for follow-up visits at the first month, and then every three months. They must also return to the clinic monthly to pick up their pills.

Counselling should be:

  • Sensitive, inclusive, and non-judgmental
    Recognize that behaviour change is difficult and human beings are not perfect
  • Presented as a personal choice
    Counselling should support the client in making a personal choice based on their needs and desires.
  • Problem solve and foster motivation
    Offer choices and tangible solutions; identify small wins and achievable next steps in reducing risk.
  • Client-driven and based on their needs, resources, and preferences
    Counselling should be interactive and tailored to the client’s specific needs and lifestyle.
  • Brief
    10-15 minute check-ins about experience with PrEP and sexual health protection plans are most effective; longer (~30 minute) sessions may be necessary at the first PrEP consultation or if specific issues arise.