Beyond Initiation: Why Flexibility and Patient Choice Matter in PrEP Management

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Released: October 30, 2026

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Prescribing PrEP is only the beginning: Successful long-term HIV prevention requires ongoing assessment of clinical factors, systemic barriers, and, perhaps of most importance, patient satisfaction. Read on to learn how we take these factors into account to recognize when and how PrEP regimens should be adjusted.

Cristina Gruta, PharmD, AAHIVP

Christina M. Madison, PharmD, FCCP, AAHIVP

Flexibility and Patient Choice in PrEP Management

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Consider This Clinical Scenario:
A 38-year-old man has been successfully receiving long-acting (LA) injectable cabotegravir (CAB) for HIV prevention for the past year. He appreciates not having to take a daily pill and has consistently attended his injection appointments.

Recently, he was diagnosed with a seizure disorder and prescribed carbamazepine. During a follow-up visit, he asks whether his new medication will interfere with his pre-exposure prophylaxis (PrEP) and whether he needs to consider another prevention option.

How Should You Approach This Situation?
Carbamazepine is a strong hepatic enzyme inducer that could significantly decrease CAB concentrations, potentially compromising its effectiveness. Coadministration with CAB is not recommended.

Similarly, it is thought that carbamazepine could have a similar effect on lenacapavir (LEN) concentrations and efficacy. As such, coadministration with LEN is also not recommended, effectively ruling out LA injectable PrEP for this individual if they continue treatment with carbamazepine.

Rather than viewing this as a reason to discontinue HIV prevention, we should recognize it as an opportunity to reassess the patient's needs and engage in shared decision-making. Assuming this patient wishes to stay on PrEP, key questions to ask include his desire and ability to take daily or event-driven oral PrEP, compared to continuing LA injectable PrEP.

When embarking on a PrEP regimen switch, a comprehensive evaluation should include reviewing the patient's complete medication list, confirming HIV-negative status using appropriate testing, evaluating renal function and hepatitis B status—especially when considering oral tenofovir-based PrEP—and discussing alternative HIV prevention options.

Discussing Options
Oral emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) may be an appropriate alternative to LA CAB if renal function and other clinical considerations permit, since it may be coadministered with carbamazepine without concern for a drug–drug interaction. In considering this change, the healthcare professional should also review the patient's preferences, anticipated medication adherence, and willingness to reconsider daily oral therapy. Any transition should be carefully planned to avoid gaps in HIV prevention coverage.

If, on the other hand, he would rather continue on an LA injectable, his PrEP provider must work with his neurologist to choose an alternative anticonvulsant that would not have disqualifying interactions with current LA injectable PrEP options, CAB or LEN.

Switching PrEP regimens may sometimes be imperative for medical reasons. However, it is often driven by patient preference, including preferred administration route, desire to avoid certain side effects, ability to adhere to oral pills or injection appointments, or a desire for the privacy that injectables can provide. Ultimately, PrEP regimen switches should not be interpreted as treatment failure. Rather, they represent an individualized response to changing clinical or personal circumstances.

Dynamic PrEP Choice
Research presented by Moses Kamya and colleagues at the 2024 Conference on Retroviruses and Opportunistic Infections (CROI) reinforces the importance of flexibility in HIV prevention.

In this dynamic choice prevention study, which was conducted in Kenya and Uganda, allowing participants to select among prevention strategies, testing approaches, and service delivery locations substantially increased the proportion of time they were covered by HIV prevention compared with standard care.

These findings underscore an important principle: PrEP persistence and effective prevention coverage are not necessarily defined by remaining on 1 medication indefinitely.

People's lives are dynamic. Relationships change, medical conditions develop, medication regimens evolve, and preferences shift. Our approach to HIV prevention should be equally adaptable.

Beyond the Labs
Although HIV testing, renal function assessment, sexually transmitted infection screening, and medication safety monitoring remain essential components of PrEP management, we should also routinely evaluate whether the current regimen continues to meet the patient's needs.

During follow-up appointments, consider asking:

Are you satisfied with your current PrEP regimen?
Have you experienced any adverse effects or started any new medications?
Has anything changed in your life that makes your current PrEP option more difficult to use?
Would you like to hear about new PrEP options?
Would you prefer to discuss another prevention option?

These conversations create opportunities to identify barriers before they lead to disengagement from care, leaving patients unprotected from a preventable infection.

The Bottom Line
As we expand the HIV prevention toolbox with daily or event-driven oral PrEP, every-2-month injectable CAB, and twice-yearly injectable LEN, our responsibility extends beyond knowing which medications are available, with additional LA agents likely to be available in the near future for PrEP.

We must understand how to safely monitor these options, recognize when a change is clinically indicated, anticipate when access barriers (ie, insurance changes) necessitate a change in therapy, and support patients through transitions in care.

The most effective PrEP strategy is one that is clinically appropriate, aligns with the patient's preferences, and can adapt to their changing circumstances.

The goal isn't simply to keep patients on PrEP. It's to keep them engaged in HIV prevention, informed about their options, and empowered to make decisions that work for their lives.

Your Thoughts
How often do you assess patients’ satisfaction with their PrEP regimen? Based on this commentary, what do you think are the most important questions to ask? Leave a comment to join the discussion!

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