HIV prevention requires nurse knowledge and advocacy.

Pre-exposure prophylaxis (PrEP) to prevent HIV has been available since July 16, 2012. However, significant numbers of new cases of HIV continue to occur globally and nationally. According to HIV.gov, an estimated 1.3 million individuals worldwide acquired HIV in 2022, with 32,100 cases in the United States. In 2021, 49% of those who died in the United States due to HIV were Black and 35% were Black women. According to the Centers for Disease Control and Prevention (CDC), in 2021, HIV disease ranked as the seventh leading cause of death among Black men and the 12th leading cause of death among Black women.

Why are new HIV cases still occurring when we have preventive treatment? One reason could be a lack of knowledge and experience among healthcare professionals to discuss, prescribe, and manage PrEP for vulnerable patients. Lack of information and discomfort with prescribing PrEP remain ongoing issues among healthcare professionals in the United States. Healthcare professionals should know how to identify appropriate candidates for PrEP, provide general education, and prescribe necessary preventive treatment.

Providers and nurses have a role to play in screening and identifying patients at risk for HIV. The provider roles include discussing the risks and benefits of PrEP, possible adverse med­ic­ation outcomes, the importance of adherence, follow-up visit frequency, specific lab testing requirements while taking PrEP, and overall prevention of other sexually transmitted infections (STIs) and unintended pregnancies.

The nurse’s role includes screening, reinforcing patient education and adherence, obtaining and monitoring lab tests and results, assisting the patient in completing prescription drug assistance forms, and scheduling initial and follow-up visits. The nurse should also perform vaccination screenings, administer all necessary vaccines, and dispense any in-office medications ordered by the provider. In addition, nurses provide patients with PrEP counseling and emotional support during their efforts to remain HIV negative.

The perfect candidate

Elaine Harvey*, an uninsured 25-year-old healthy, cis-gender, Black woman, arrives at her provider’s office for her annual well-woman examination. She reports a 2-week history of a nonpruritic peeling rash on her hands and feet and thinning hair. She also requests a prescription for birth control. She reports a fear of needles and prefers not to have an injection for contraception.

Ms. Harvey tells the provider that she and her husband have been separated for 10 months. For 6 months, she’s had a new cis-gender male sex partner. They’ve engaged in condomless vaginal sex at least five times. She also reports having occasional receptive anal sex with her husband.

Medical, social, and family history

Ms. Harvey has no known drug or food allergies. She reports a history of asthma but hasn’t required medications since age 18. She’s had no prior surgeries or hospitalizations, and she’s up-to-date on her immunizations, including COVID-19 and influenza vaccines. Ms. Harvey completed her Hepatitis B vaccines as a child and her human papillomavirus (HPV) vaccines as a teenager. Her medications include a daily multivitamin and over-the-counter pain relievers for menstrual cramps as needed.

Ms. Harvey reports smoking cigars and marijuana occasionally. She drinks two glasses of wine with dinner at least twice weekly and two glasses with friends on Saturday nights. Her mother has type 2 diabetes, and her father has hypertension. Both parents are alive and take oral medications to manage these conditions.

Sexual health history

Ms. Harvey tells the nurse that she had a condomless vaginal and oral sexual encounter 14 days ago. When asked why she chooses not to use condoms, Ms. Harvey says, “He just doesn’t like using condoms, so we don’t use them.” She also reports that the new partner told her that he’s HIV negative. Ms. Harvey says that although she and her husband no longer live together, they still have condomless sex because “I love him, and he’s the father of my children.” Ms. Harvey has seen her husband’s negative HIV test results.

Review of systems and physical exam

During the review of systems, the provider asks Ms. Harvey several questions to determine whether she has any signs or symptoms of acute HIV or other STIs such as chlamydia, gonorrhea, or syphilis. (See Signs and symptoms.)

Ms. Harvey’s physical exam and test results indicate possible HIV or another STI. Significant findings include a plantar palmar rash, alopecia, enlarged right inguinal lymph node, reactive rapid plasma reagin (RPR) with a titer of 1:32, and reactive treponema pallidum particle agglutination (TPPA). RPR, a nontrepo­ne­mal serologic test, detects syphilis by measuring antibodies produced in response to the infection. TPPA serves as a confirmatory test that specifically detects antibodies against Tre­po­nema pallidum, the bacterium that causes syphilis; a titer of 1:32 suggests active infection, which supports the secondary syphilis diagnosis. (See Significant findings.)

HIV vulnerability

According to the CDC’s per-act probability of acquiring HIV, Ms. Harvey’s sexual history and confirmed secondary syphilis make her vulnerable for HIV acquisition. For example, she has two sex partners, she engages in condomless sex with both, and she has condomless receptive anal sex. (See Per-act risk.)

In addition, according to the CDC, Black/African American individuals are impacted by HIV more than other racial groups, with a lifetime risk of 1 in 20 for Black men (compared to 1 in 132 for White men) and 1 in 48 for Black women (compared to 1 in 880 for White women). Black heterosexuals also are disproportionately affected by HIV despite the common misperception that HIV only affects men who have sex with men. In 2018, heterosexuals accounted for 24% of the 37,968 new HIV diagnoses. Heterosexual men accounted for 8% of new HIV diagnoses, and heterosexual women accounted for 16%. (See Online PrEP screening and assessment tools)

PrEP candidacy

Ms. Harvey’s sexual history (multiple sex partners and condomless sex) and diagnosis of secondary syphilis make her an ideal candidate for PrEP. She can take PrEP for as long as she experiences risks for acquiring HIV. For some, taking PrEP may be a lifetime commitment. Others can discontinue PrEP when it’s no longer needed. (See Who’s eligible.)

PrEP education

Providers and nurses should inform patients that PrEP, when taken as prescribed, reduces the risk of acquiring HIV from sex by about 99%. Patients should know that they can receive the medication orally (Truvada is indicated for those at risk for HIV via sex or injection drug use. Descovy is indicated for those at risk via sex; it’s not indicated for those assigned female at birth who are at risk via receptive vaginal sex) or by injection (approved only for individuals at risk via sex). To receive PrEP, patients must weigh at least 77 pounds (35 kg).

When educating patients about PrEP, discuss the risks and benefits, possible side effects, laboratory testing requirements prior to and while taking PrEP, and prevention strategies. Ms. Harvey’s nurse talks to her about condom use, adherence to the medication regimen, medication side effect management, and follow-up visit frequency and attendance. The nurse also explains that Ms. Harvey should go to the nearest urgent care or notify her provider if she experiences serious side effects or symptoms of acute HIV. (See PrEP medications and patient education)

Because Ms. Harvey has no health insurance, the nurse helps her complete applications for prescription drug assistance. Although these applications are short and easy to complete, assistance from a nurse or medical assistant can help expedite the process. In addition, many HIV-related community-based organizations have PrEP navigators who support this process.

Pre-PrEP lab tests

Patients should receive testing for HIV within 1 week before initiating PrEP and every 3 months after. Options include nucleic acid test, antigen/antibody lab test, rapid antigen/antibody test, and antibody test.

Providers should assess patients with recent exposure to HIV (within 4 weeks before initiating PrEP) for signs and symptoms of acute HIV (for example, fever, fatigue, myalgia, skin rash, headache, pharyngitis, cervical adenopathy, arthralgia, night sweats, and diarrhea). The CDC recommends laboratory-based HIV antigen/antibody tests because they’re more sensitive to detecting acute HIV than rapid antigen/antibody tests. (See PrEP testing)

The CDC recommends syphilis testing at initial screening and semi-annually or more frequently for vulnerable patients. Ms. Harvey has multiple signs of secondary syphilis and a positive TPPA test, which confirms the diagnosis. The provider prescribes a single 2.4 million unit intramuscular dose of long-acting penicillin G benzathine.

Recommended vaccines

Hepatitis B, a serious disease caused by the Hepatitis B virus (HBV), attacks the liver and can result in lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death. HBV spreads via blood, semen, and other body fluids during sex; sharing of needles, syringes, and other drug-injection equipment; or during pregnancy and delivery. The CDC recommends that all patients taking PrEP whose HBV testing (for example, a negative HBV surface antibody) indicates no immunity to HBV receive a hepatitis B vaccine.

HPV, a common virus, can cause cancers later in life. At any age, having a new sex partner presents a risk for HPV. The vaccine protects individuals, including children, before they ever have contact with the virus. The CDC recommends encouraging all patients taking PrEP to receive the HPV vaccination.

In Ms. Harvey’s case, in addition to being tested for HIV, her provider tests for genital and extragenital gonorrhea and chlamydia, HBV, hepatitis C, syphilis, creatinine clearance, and pregnancy. The provider reviews Ms. Harvey’s immunization history and finds it adequate, but offers the recent influenza and COVID-19 vaccine. The provider also offers education and a choice of reliable contraception.

Follow-up visits

All patients who’ve recently started taking PrEP should receive a follow-up call from the provider or nurse to assess for adverse medication effects, signs of acute HIV or other STIs, and medication adherence. If needed, schedule an immediate in-person follow-up visit; if the patient is stable, schedule a 3-month follow-up visit. Repeat HIV testing at least every 3 months or sooner for patients who require more frequent testing based on their per-act probability of acquiring HIV. In addition, include assessments for adverse medication effects, signs of acute HIV or other STIs, and medication adherence in follow-up visits.

At each follow-up visit, encourage the patient to continue taking PrEP. If the patient remains asymptomatic for STIs and acute HIV and reports no adverse medication effects, a physical exam isn’t required at each follow-up.

Because of Ms. Harvey’s confirmed secondary syphilis diagnosis, the provider follows the CDC’s 2021 STI Guidelines and schedules a clinical and serologic evaluation for syphilis at 6 and 12 months after treatment.

Healthcare professional education

Many individuals remain unaware of PrEP, even 11 years after the Food and Drug Administration approved it. Although many current healthcare initiatives focus on the coronavirus, re-introducing PrEP and educating and encouraging providers to prescribe the treatment for patients such as Ms. Harvey may help solve the problem of low PrEP uptake.

Medical and nursing school curricula should include PrEP as part of routine preventive healthcare education. In addition, annual competency training for all healthcare professionals should incorporate instruction about PrEP indications, side effects, pertinent recommended lab testing, comprehensive HIV prevention and reproductive life plans, and STI testing and treatment.

Provide the best defense

Conversations about PrEP should occur between patients and all healthcare providers and be reviewed with vulnerable patients at every office visit. Healthcare providers and nurses must remind patients that, although PrEP can prevent HIV, it doesn’t protect against other STIs or unintended pregnancy. In addition, healthcare professionals must give special consideration to the topics of implicit bias, trauma-informed care, social determinants of health, the importance of cultural competence, and the need for PrEP navigation services.

Nurses’ vital role in ensuring patients receive the information they need to protect themselves from HIV includes incorporating routine PrEP discussions into all sexual health conversations, regardless of perceived risks. Practice culturally competent care by demonstrating respect, empathy, and understanding, and recognize the diverse experiences and needs of Black women, without generalizing.

In addition, collaborate with other healthcare team members to ensure seamless PrEP access and continuity of care. Advocate for policy changes that address systemic barriers to PrEP access, such as insurance coverage and affordability, and engage in community outreach and education initiatives to increase PrEP awareness and uptake among Black women. Finally, stay informed about emerging research on PrEP effectiveness and best practices. Your knowledge and advocacy serve as the best defense against HIV.

*Name is fictitious.

The authors work at the Cizik School of Nursing at UTHealth in Houston, Texas. Sheryl Malone-Thomas is an assistant professor and a leading clinical expert in HIV prevention and care. Veronica Brady is an assistant professor who specializes in research and care of women with HIV and diabetes. Emily Anne Barr is an assistant professor,  midwife, and pediatric nurse practitioner specializing in the care and treatment of youth and women with HIV.

American Nurse Journal. 2025; 20(3). Doi: 10.51256/ANJ032506

References

Authors’ note: The authors are passionate about HIV prevention and hope that readers will implement what they learn from this continuing education article. Ending the HIV epidemic will require the collaboration of healthcare providers from every discipline. We gathered much of the information presented here from federal and state websites, some of which are no longer available or have been altered. For example, some now include this statement, which contains inaccuracies: “Per a court order, HHS is required to restore this website as of 11:59PM ET, February 14, 2025. Any information on this page promoting gender ideology is extremely inaccurate and disconnected from the immutable biological reality that there are two sexes, male and female. The Trump Administration rejects gender ideology and condemns the harms it causes to children, by promoting their chemical and surgical mutilation, and to women, by depriving them of their dignity, safety, well-being, and opportunities. This page does not reflect biological reality and therefore the Administration and this Department rejects it.”  Where possible, we’ve provided archived snapshots of the pages we used as sources.

AIDS Education & Training Center. Prescribing PrEP. A guide for healthcare providers. January 11, 2022. aidsetc.org/prep

Benjamin TM. Improving PrEP adherence. Am Nurse J. 2023;18(11):22-24. doi:10.51256/ANJ112323 https://www.myamericannurse.com/improving-prep-adherence/

Centers for Disease Control and Prevention. A guide to taking a sexual history. cdc.gov/std/treatment/sexualhistory.pdf

Centers for Disease Control and Prevention. Fast Facts: HIV in the United States. cdc.gov/hiv/data-research/facts-stats/index.html (Editorial note: You also can find this information at the following URL without the inaccurate statement: http://web.archive.org/web/20250115034924/cdc.gov/hiv/data-research/facts-stats/index.html)

Centers for Disease Control and Prevention. HIV diagnoses, death, and prevalence. May 21, 2024. cdc.gov/hiv-data/nhss/hiv-diagnoses-deaths-prevalence.html (Editorial note: You also can find this information at the following URL without the inaccurate statement: http://web.archive.org/web/20250108114353/cdc.gov/hiv-data/nhss/hiv-diagnoses-deaths-prevalence.html)

Centers for Disease Control and Prevention. HIV mortality 2022. cdc.gov/hiv-data/media/pdfs/nhss/nhss-surveillance-slideset-mortality.pdf?CDC_AAref_Val=https://www.cdc.gov/hiv/pdf/library/slidesets/cdc-hiv-surveillance-slideset-mortality-2021.pdf (Editorial note. This page has been reinstated after having been removed. We can’t currently verify it’s accuracy.)

Centers for Disease Control and Prevention. HIV risk and prevention estimates. cdc.gov/hivpartners/php/riskandprevention/?CDC_AAref_Val=https://www.cdc.gov/hiv/risk/estimates/riskbehaviors.html (Editorial note: If you’re unable to access this content at its original URL, you can find it at http://web.archive.org/web/20241202124219/cdc.gov/hivpartners/php/riskandprevention/?CDC_AAref_Val=https://www.cdc.gov/hiv/risk/estimates/riskbehaviors.html)

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Centers for Disease Control and Prevention. STI Treatment Guidelines 2021. https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf

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HIVinfo. Pre-exposure prophylaxis (PrEP) December 11, 2023. hivinfo.nih.gov/understanding-hiv/fact-sheets/pre-exposure-prophylaxis-prep

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Mayo Clinic. HIV/AIDS. mayoclinic.org/diseases-conditions/hiv-aids/symptoms-causes/syc-20373524

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Rogers BG, Tao J, Maynard M, et al. Characterizing the impact of COVID-19 on pre-exposure prophylaxis (PrEP) care. AIDS Beh. 2021;25(11):3754-7. doi:10.1007/s10461-021-03337-2

Sell J, Chen R, Huber C, Parascando J, Nunez J. Primary care provider HIV PrEP knowledge, attitudes, and prescribing habits: A cross-sectional survey of late adopters in rural and suburban practice. J Prim Care Community Health. 2023;14: 21501319221147254. doi:10.1177/21501319221147254

Troutman J, Ingram LA, Gaddist B, Robillard A, Qiao S. African American women’s current knowledge, perceptions, and willingness of PrEP use for HIV rpevention in the South. J Healthc Sci Humanit. 2021;11(1):51-72.

World Health Organization. HIV and AIDS. July 22, 2024. who.int/news-room/fact-sheets/detail/hiv-aids

Key words: women’s health, HIV, HIV pre-exposure prophylaxis, PrEP