#171: Always Be PrEP-ared! HIV Prophylaxis in Adolescents

March 18, 2026 | By Sam Masur

Audio

An ounce of prevention is worth a pound of cure! In this episode, we learn all about HIV prevention in adolescents with our guest, Dr. Alex Golec of Johns Hopkins Children’s Center. We break down the indications, treatment options, and monitoring of prescribing pre and post-exposure prophylaxis in the outpatient setting. We even talk about STI prevention with DoxyPEP! 

Prophylaxis Pearls

1. PrEP is patient-centered. A patient does not have to be “high risk” to offer PrEP—a patient request alone is enough.
2. Adherence matters more than the specific regimen. All PrEP options are highly effective when taken correctly, so the “best” choice is the one a patient can access and reliably use.
3. PEP can be a doorway to PrEP. Any patient completing PEP after a high-risk exposure should be reassessed for ongoing risk and offered PrEP to mitigate HIV risk.

Pre-exposure Prophylaxis

Pre-exposure prophylaxis (PrEP) is the use of medication to prevent HIV acquisition. PrEP should be considered in patients who are at increased risk for acquiring HIV, including patients who participate in high risk sexual practices, have a history of STIs, men who have sex with men, or those living in an area of high HIV prevalence. However, if any patient requests PrEP, it should be discussed and offered to them if there are no contraindications (Pediatrics, 2022). 

Initiating PrEP

Ruling out active HIV infection is essential before starting a patient on PrEP. Order a 4th generation antigen/antibody test at minimum and consider an HIV RNA level if there is a recent possible exposure or current PrEP use. Also obtain recommended STI testing (including hepatitis B and C screening) as well as renal function and a lipid panel (TAF).  The minimum weight for PrEP is 35 kg (CDC, 2025). There is no minimum age.

Treatment Options

1. Tenofovir disoproxil fumarate-emtricitabine (TDF-FTC) or Truvada is a once daily medication. It is the only PrEP regimen also available as a generic. Possible adverse effects include decreased renal function and bone loss with long term use. It comes as a large pill that may be difficult to swallow for some patients. TDF has a small risk of kidney injury and is contraindicated in GFR<60. 

2. Tenofovir alafenamide-emtricitabine (TAF-FTC) or Descovy is a once daily medication. Possible adverse effects also include decreased renal function and bone loss with long term use, however both of these effects are less pronounced than with TDF. TAF is contraindicated in GFR<30.

3. Cabotegravir is a long acting injectable. It is administered once monthly for two months (loading period) followed by every 2 months thereafter. It must often be administered in a specialty clinic and may be difficult to obtain insurance approval (expert opinion). 

All treatment options can cause upset stomach, nausea, and headache in the first few days or weeks of taking the medication, or what Dr. Golec calls the “startup syndrome.”

Choosing a Regimen

Often the best PrEP regimen is the one the patient has access to and will adhere to. Know the laws of the state in which you are practicing and whether HIV prevention can be offered confidentially to adolescents. The only absolute contraindications to PrEP are significantly impaired renal clearance, allergy to the medication, or active HIV infection (CDC, 2025). Active hepatitis infection is not a contraindication, but should be screened for because tenofovir may partially treat hepatitis B and abrupt discontinuation could lead to a flare.

All options are comparable in efficacy when adhered to, which can be a challenge in adolescents. Discuss the importance of medication adherence with each patient. Consider injectable cabotegravir in patients who have difficulty adhering to once daily medication. 

Follow Up

Dr. Golec recommends checking in around 2 weeks (can be via phone or patient messaging) to ensure patients are adhering to and tolerating the medication without any side effects. After this, patients on oral PrEP should be seen and retested for HIV every 3 months. Patients on injectable PrEP should be seen and retested for HIV every 2 months. Retest with the HIV antigen/antibody test AND HIV RNA viral load (CDC, 2025). Remember, poor adherence to PrEP puts patients at higher risk for active HIV infection which is a contraindication to continuing PrEP. 

Screen renal function annually for patients on oral PrEP or more often in those in patients at higher risk. Additionally, check lipid panels annually for patients on TAF (expert opinion). 

Assess for and promote adherence at every follow up visit! Use tactics like motivational interviewing, pill boxes, or phone alarms to increase adherence to medication (expert opinion).

Discontinuing PrEP

Patients can stop taking PrEP whenever they are ready. Utilize shared decision making in patients that have lowered their risk of acquiring HIV. 

Post-exposure Prophylaxis

Post-exposure prophylaxis (PEP) is the use of medication to prevent acquisition of HIV in someone who may have recently been exposed to the HIV virus. 

Treatment Options and Timing

PEP should be taken as soon as possible after a potential exposure and must be started within 72 hours to be effective. There are two CDC recommended treatment options for PEP (CDC, 2025): 

1. TDF-FTC plus raltegravir* OR dolutegravir for 28 days.
2. TDF-FTC plus darunavir AND ritonavir for 28 days.

*Taken twice daily. All other options listed are taken once daily. 

There are no absolute contraindications to PEP. Because these medications are less common and more difficult to obtain, Dr. Golec recommends calling the pharmacy to ensure patients are able to pick up the medications in a timely manner; any PEP regimen is better than none.

Keep in mind that a possible exposure to HIV can be very emotional for teens. Create a safe space for conversation, and lean on any support staff you may have available including social work, child life, or child psychology (expert opinion and producer’s note).

Follow Up

Regular appointments are crucial to reassess risk in patients taking PEP. Consider transitioning to PrEP after completing a full course of PEP in patients who remain at higher risk for acquiring HIV. 

DoxyPEP

Doxycycline post-exposure prophylaxis is a newer off-label treatment regimen to prevent sexually transmitted infections (gonorrhea, chlamydia, and syphilis) in high risk populations. DoxyPEP is recommended for men who have sex with men who are 18 years and older, however it can be considered in other populations on a case-by-case basis. 

DoxyPEP should be taken within 72 hours of unprotected sex. Remember 3, 2, 1 when prescribing DoxyPEP: take it within 3 days of exposure; take 200 milligrams; and take it as a 1 time dose (NEJM, 2023). Consider prescribing several doses of DoxyPEP ahead of time and check-in with patients often, especially if they need frequent refills (expert opinion).

Access, Disparities, and When to Refer

General pediatricians should feel empowered prescribing PrEP, PEP, and DoxyPEP and promoting adolescent sexual health along with STI prevention and treatment. Keep in mind that many patients do not have access to subspecialty services or pharmacies that have these medications available.   Sexual and reproductive health should be discussed routinely with all adolescents (Pediatrics, 2022). 

Patients with complex medical histories or on chronic medications (especially antiseizure medications) should be referred to an adolescent medicine or infectious disease specialist (expert opinion).

Links

National Clinician Consultation Center

844-ASK-NCCC (275-6222)

HIV Hotlines and Warmlines

PrEPline: 1-855-448-7737 

9 am to 8 pm EST, Monday through Friday

PEPline: 1-888-448-4911

9 am to 8 pm EST, Monday through Friday; 11 am to 8 pm EST, weekends and holidays (non-occupational)

11 am to 8 pm EST, seven days a week (occupational) 

Goal

Listeners will gain the knowledge and confidence to counsel adolescents on HIV prevention and to safely prescribe, monitor, and support use of PrEP, PEP, and DoxyPEP in the outpatient setting.

Learning Objectives

After listening to this episode, listeners will…  

1. Identify which patients should be offered PrEP and outline the evaluation prior to initiating PrEP including HIV testing and baseline labs.
2. Compare available PrEP regimens based on efficacy, contraindications, side effects, and adherence considerations.
3. Implement appropriate follow-up, monitoring, and adherence-support strategies for patients on PrEP.
4. Initiate timely and effective PEP after potential HIV exposure.
5. Describe the indications, dosing, and counseling points for DoxyPEP.

Disclosures

Dr Golec reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Burch C, Nwora C, Golec A, Masur S. “#171: Always be PrEP-ared! HIV Prophylaxis in Adolescents.” The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ March 18, 2026.