Pre-Exposure Prophylaxis (Prep) Screening For Substantial Risk and Eligibility

Pre-Exposure Prophylaxis (PrEP) Screening for Substantial Risk and Eligibility
1. Facility Information
Facility Name
Date of Initial Client Visit (dd/mm/yyyy) __ __ /__ Person Completing Form
__ /__ __ __ __
2. Client Information
First Name Middle Name Surname
Address Telephone #
Client ID Number
3. Client Demographics
What was your sex at birth? ☐ Male ☐ Female ☐ Other (specify):
___________
☐ No response
What gender do you currently ☐ Male ☐ Female

identify with? ☐ Transgender (male to female) ☐ Transgender (female to
male)
☐ Other (specify): ___________
☐ No response
What is your age? (Specify

_______
number of years.)
4. Screening for Substantial Risk for HIV Infection

Client is at substantial risk if he/she belongs
Question Prompts for Providers
to categories ❶, ❷ or ❸ below
❶ If client is sexually active in a high HIV Have you been sexually active in the last 6
prevalence population or reports ANY months?
one of the below in the last 6 months
☐ Reports vaginal or anal intercourse In the last 6 months, " have you had sex with
without condoms with more than one more than one partner"
partner
In the last 6 months, did you use condoms
consistently during sex?
☐ Has a sex partner with one or more HIV In the last 6 months, have you had a sex partner
risk: who:
● Is living with HIV?
● Injects drugs?
● Has sex with men?
● Is a transgender person?
● Is a sex worker?
● Has sex with multiple partners without

condoms?
☐ History of a sexually transmitted In the last 6 months, have you had an STI?
infection (STI)
based on self-report, lab test, syndromic
STI treatment
☐ History of use of post-exposure In the last 6 months, have you taken post-exposure
prophylaxis (PEP) prophylaxis (PEP) following a potential exposure
to HIV?
Do you have a history of (or have you
experienced) sexual abuse/gender-based
violence?"
❷ If client reports history of sharing In the last 6 months, have you shared injecting
injection material or equipment in the last material
6 months with other people?
☐ History of sharing injection material or

equipment
❸ If client reports having a sexual partner Is your partner HIV positive?
in the last 6 months who is HIV positive Is he/she on ART?
AND who has not been on effective* HIV
treatment (i.e., the partner has been on What was the last viral load result?
ART for fewer than 6 months or has
inconsistent or unknown adherence)
☐ History of HIV-positive sex partner not
on effective treatment
5. PrEP Eligibility
Client is eligible if he/she
fulfills ALL the criteria
below:
☐ HIV negative Date client tested: (dd/mm/yyyy): __ __ /__ __ /__ __ __ __
Date client received test results: (dd/mm/yyyy): __ __ /__ __

/__ __ __ __
Test result: ☐ Negative

☐ Positive (Refer to HIV medical care.)
☐ Inconclusive (Re-test in 14 days.)
Type of test used: ☐ Determine ☐ Unigold ☐ ELISA ☐ Other

(specify):
☐ At substantial risk of
At least one item/risk in Section #4 above is ticked
HIV
☐ Has no
signs/symptoms of See Section #6 below to confirm no recent exposure to HIV
acute HIV infection
☐ Has creatinine
clearance (eGFR) >60 Result: _____________ Date of creatinine test (dd/mm/yyyy): __ __
ml/min /__ __ /__ __ __ __
If all boxes in Section 5 are ticked, offer PrEP.
6. Recent Exposure to HIV

Ask the client:
In the past 72 hours, have you had sex without a condom with ☐ Don’t
someone whose HIV status is positive or not known to you, or ☐ Yes* ☐ No
know
have you shared injection equipment with someone whose
HIV status is positive or unknown to you?
In the past 28 days, have you had symptoms of a cold or flu,

☐ Don’t
including fever, fatigue, sore throat, headache, or muscle pain ☐Yes** ☐ No
know
or soreness?
* If the client reports potential exposure to HIV within past 72 hours, do NOT offer PrEP.
Follow facility procedures to evaluate further or refer for evaluation for post-exposure
prophylaxis (PEP).
** If the client reports flu-like symptoms or other signs of acute HIV infection, do NOT offer
PrEP and evaluate further, following facility procedures to diagnosis acute HIV infection.
7. Client readiness for PrEP

Are you interested in taking a daily oral pill that will reduce your risk of HIV?"
☐ PrEP offered
● ☐ PrEP accepted.
Date eligible (dd/mm/yyyy): __ __ /__ __ /__ __ __ __
Date initiated (dd/mm/yyyy): __ __ /__ __ /__ __ __ __ Same-day initiation recommended.
● ☐ PrEP declined. (If declined, see Reasons for Declining PrEP, below).
If no, why not? Are there other prevention services we can refer the client to in the meantime?
Reasons for Declining PrEP
(Check all that apply.)
☐ No need for PrEP
☐ Does not wish to take a daily medication
☐ Concerns about side effects
☐ Concerns about what others might think
☐ Concerns about time required for clinic follow-up
☐ Concerns about safety of medication
☐ Concerns about effectiveness of medication
☐ Other (specify):
☐ Referred for PEP evaluation
☐ Referred for PCR/HIV Ag test or follow-up HIV re-testing (if suspicion of acute HIV infection)

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Pre-Exposure Prophylaxis (PrEP) Screening for Substantial Risk and Eligibility

What gender do you currently ☐ Male ☐ Female

☐ Other (specify): ___________

What is your age? (Specify

4. Screening for Substantial Risk for HIV Infection

● Has sex with men?

● Has sex with multiple partners without

☐ History of sharing injection material or

☐ HIV negative Date client tested: (dd/mm/yyyy): __ __ /__ __ /__ __ __ __

Date client received test results: (dd/mm/yyyy): __ __ /__ __

Test result: ☐ Negative

Type of test used: ☐ Determine ☐ Unigold ☐ ELISA ☐ Other

If all boxes in Section 5 are ticked, offer PrEP.

6. Recent Exposure to HIV

In the past 28 days, have you had symptoms of a cold or flu,

7. Client readiness for PrEP

Date initiated (dd/mm/yyyy): __ __ /__ __ /__ __ __ __ Same-day initiation recommended.

☐ No need for PrEP

☐ Does not wish to take a daily medication

☐ Concerns about side effects

☐ Concerns about what others might think

☐ Concerns about time required for clinic follow-up

☐ Concerns about safety of medication

☐ Concerns about effectiveness of medication

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☐ HIV negative Date client tested: (dd/mm/yyyy): / /

Date client received test results: (dd/mm/yyyy): /

Date initiated (dd/mm/yyyy): / / Same-day initiation recommended.