Click below to download the full *updated* Dear Colleague Letter.

Dear Colleague,

We’re writing to share with you recommendations on how to incorporate new developments in HIV prevention and care into your practice.

The San Francisco Department of Public Health recommends that you:

1. Screen all sexually active MSM, trans women, and trans men who have sex with men for STDs, using urine, pharyngeal, and rectal NAAT testing, and a serum RPR for syphilis, every 3 months, regardless of HIV serostatus.

Updated CDC recommendations on which HIV tests to use when prescribing daily PrEP, and how often to screen for bacterial STIs: CDC now recommends antigen/antibody testing over antibody-only testing; they also provide guidance on interpretation of HIV RNA testing used for PrEP. See details below. Furthermore, CDC now recommends that MSM “at high risk for recurrent STIs” undergo screening every three months.

2. Offer daily PrEP for persons <18 years old who are at-risk for HIV. Emtricitabine/tenofovir disoproxil fumarate (Truvada®) is now approved for persons < 18 years of age (weighing >35 kg) by the FDA. See details below.

3. Consider a “2-1-1” dosing regimen for men who have sex with men (MSM) who are ambivalent about daily pre-exposure prophylaxis for HIV (PrEP).

There is a non-daily dosing strategy for PrEP that was studied in MSM in France and Canada, and is being used in some clinics in Europe and Canada. This non-daily strategy, also known as “Intermittent”, “Event-Driven,” “Sex-Driven,” “On Demand,” or “2-1-1” PrEP, may be appropriate for some MSM. SFDPH has released guidance on this dosing strategy (see below) for MSM who do not want to use daily emtricitabine/tenofovir disoproxil fumarate (also known as FTC/TDF or Truvada®), which is currently the only FDA-approved dosing strategy for PrEP in the United States.

4. Inform patients living with HIV that maintaining an undetectable viral load eliminates the risk of transmitting HIV to sexual partners. Here is a link to the UCSF HIVInSite article supporting the Undetectable = Untransmittable (“U=U”) message.

5. Discuss the risks of dolutegravir use with women of child-bearing age, and discontinue use if women are considering pregnancy.

Recent data suggest a possible association between use of the antiretroviral drug dolutegravir by women around the time of conception, and subsequent neural tube defects in their infants. The U.S. Public Health Service has issued recommendations regarding the use of dolutegravir (Tivicay®) for ongoing antiretroviral therapy (ART) or post-exposure prophylaxis (PEP) by women of childbearing potential (this also applies to co-formulations of dolutegravir such as dolutegravir/abacavir/lamivudine, or Triumeq®, and dolutegravir/rilpivirine, or Juluca®). More details, as well as links to USPHS recommendations can be found below.