PrEP Initiation Note

Encounter date/time: [Date and time]

Location/clinic: [Clinic or facility]

Visit type: [new patient / established patient / same-day start]

Author: [Name, credentials]

Patient identifiers: [Per system policy]

Preferred name/pronouns: [Preferred name; pronouns] (Only include if collected)

Interpreter: [Language and modality] (Only include if used)

Chief Concern

[Patient-stated reason for visit, optionally with brief direct quote]

History of Present Illness

[Trigger for today's visit] [Prior PrEP and/or PEP use with adherence, tolerance, and reason for stopping if applicable] [Modality preference (daily oral vs injectable) and rationale] [Recent exposure timing, especially within 72 hours if PEP-to-PrEP transition may apply] (If PrEP/PEP history was not obtained, state "PrEP/PEP history not assessed today.")

HIV Risk Assessment

(Document explicitly; do not infer risk from demographics or identity.)

Sexual History (5 Ps)

• Partners: [Number, genders, HIV status known/unknown, partner viral suppression if HIV-positive]
• Practices: [Anatomic exposures: receptive anal / insertive anal / vaginal or front-hole / oral] [Condom use by practice]
• Protection: [Current prevention methods: condoms / partner on PrEP / treatment as prevention / other]
• Past STIs: [Type(s), dates, treatment]
• Pregnancy: [Current status / contraception / conception plans / breastfeeding or chestfeeding] (Include only if applicable)

Injection Risk

(Include only if injection-related exposures are relevant; otherwise omit this subsection.)

• [Injection drug use: substances, frequency]
• [Shared equipment: needles, cookers, cottons, rinse water]
• [Syringe service program access and harm reduction linkage]

Acute HIV Screen

(Required before initiation. If not performed, state "Acute HIV screen not performed" and do not indicate clearance to start PrEP.)

• Symptoms in past month consistent with acute HIV: [Yes / No] [If yes: fever, rash, pharyngitis, myalgias, lymphadenopathy with dates]
• Recent high-risk exposure: [Yes / No] [Timing and details if yes]
• Current or recent antiretroviral exposure: [None / Describe regimen and dates with implications for test interpretation]

Medical History

(Problem-list format; include only PrEP-relevant conditions.)

• [Kidney disease or nephrotoxic medication use]
• [Hepatitis B status and vaccination history]
• [Hepatitis C status]
• [Bone health concerns if considering tenofovir-based PrEP]
• [Liver disease if considering CAB]
• [Mental health or social factors affecting adherence]
• [Drug allergies, including prior injection reactions]

Medications

Current medications: [Reconciled list including OTC and supplements]

Interaction screen: [None identified / List specific concerns] (For oral PrEP: nephrotoxic agents. For CAB: strong enzyme inducers.)

Review of Systems

(Focused ROS only.)

• Acute HIV symptoms: [Present / Absent] [Details if present]
• STI symptoms: [Dysuria / Discharge / Lesions / None]
• Renal/hepatic symptoms: [Present / Absent] (Include if relevant)
• Pregnancy symptoms: [Present / Absent] (Include if applicable)

Objective

Vitals

[BP] [HR] [Temp] [Resp] [SpO2] Weight: [Value and units]

Physical Exam

[Targeted exam findings if symptomatic (pharyngeal, genital, rectal, skin, lymph nodes) or assessing injection site suitability for CAB] (If asymptomatic: "No exam performed; counseling-focused visit.")

Point-of-Care Tests

(Include only if performed.)

Test	Result	Date/Time
[Rapid HIV Ag/Ab / Pregnancy test / Urinalysis]	[Result]	[Date/time]

Baseline Testing

(Document results if available or orders if pending. Never copy forward prior results without exact test type and date.)

HIV Testing

(Required. Never document "HIV negative" without specifying test type and date.)

• HIV Ag/Ab: [Test type: lab-based 4th gen / POC] [Date] [Result]
• HIV-1 RNA: [Ordered / Result / Not indicated] (Include if acute symptoms, recent ARV exposure, or CAB initiation protocol)
• [If discordant/indeterminate: deferral decision and repeat testing plan]

STI Testing

• Syphilis serology: [Test, date, result]
• GC/CT NAATs: Pharyngeal [ordered / result / declined], Rectal [ordered / result / declined], Urogenital [ordered / result / declined] (Document sites based on exposures. If declined, note reason.)

Renal Function

(Oral PrEP only.)

• Serum creatinine: [Value, date] eCrCl: [Value]
• Eligibility: [Eligible for F/TDF (eCrCl ≥60) / Eligible for F/TAF (eCrCl ≥30) / Ineligible due to renal function]

Hepatitis B

(Oral PrEP only.)

• HBsAg: [Result] anti-HBs: [Result] anti-HBc: [Result if performed]
• Interpretation: [Immune / Susceptible / Infection present or possible] [Vaccination or referral plan as indicated]

Lipids

(F/TAF only.) [Total cholesterol, HDL, LDL, triglycerides with date]

Additional Testing

(Include only if indicated.)

• Pregnancy test: [Date, result] (If relevant to regimen counseling)
• HCV: [Date, result] (If risk factors present)

Assessment

[Concise synthesis (2–3 sentences): HIV acquisition risk context (sexual and/or injection-based), current HIV testing status (negative and adequate to start vs pending with deferral plan), and suitability for selected modality based on documented screening] (If required screening is missing, state: "Eligibility cannot be determined because [specific element] not yet completed.")

Problem list: [Active, PrEP-relevant problems]

Plan

HIV Prevention: PrEP Initiation

Shared Decision-Making: [Options discussed: daily oral vs injectable] [Patient preference and reasons] [Contraindications screened: none identified / list concerns] Decision: [Start specific regimen / Defer pending reason]

Regimen Details

Oral PrEP: (Include if selected.)

• Drug: [F/TDF / F/TAF] [Rationale: anatomic coverage, renal eligibility, HBV considerations]
• Dose/instructions: [Dose, daily schedule, administration guidance]
• Quantity/refills: [Quantity with refills aligned to HIV testing cadence]
• Same-day start: [Yes / No] [If yes: safety rationale and trigger conditions for hold]

Injectable Cabotegravir: (Include if selected.)

• Schedule: [Initial dose date, 1-month second dose, then every 2 months]
• Oral lead-in: [Used / Waived] [Rationale]
• If administered today: [Dose] [Site] [Lot/expiration] [Administrator] [Patient tolerance]
• Tail-period counseling: [Missed/discontinued injection plan, bridging strategy, 12-month HIV monitoring after stopping]

Counseling Completed:

• [Adherence plan: reminders, pharmacy support, barrier mitigation]
• [Risk reduction: PrEP does not prevent bacterial STIs; condom strategies; harm reduction if applicable]
• [Acute HIV warning signs and instructions to contact clinic]
• [Expected side effects vs urgent symptoms]
• [Time to protection; additional prevention during lead-in period]
• [Confidentiality and preferred contact methods]

Follow-Up: [Next visit date and type] [HIV testing interval: at least every 3 months for oral / before each injection for CAB] [STI screening frequency] [Renal monitoring if oral PrEP] [Lipid monitoring if F/TAF]

STI Screening and Prevention

• Tests ordered: [List with site-specific rationale]
• Treatment: [If symptomatic or positive, list treatment provided or planned]
• Vaccinations: [HBV if susceptible / HAV / HPV / mpox as indicated]
• Doxy-PEP: [Eligibility reviewed / Discussed / Not indicated] (For MSM or transgender women with bacterial STI in past 12 months)

Safety Monitoring and Care Coordination

Renal/Hepatitis Monitoring: [Monitoring interval] [If HBV infection present: coordination plan and hepatic flare counseling if tenofovir stopped] (Oral PrEP only.)

Reproductive Health: [Pregnancy test result] [Contraception plan] [PrEP in pregnancy/breastfeeding counseling] [Prenatal care coordination if pregnant] (Include if applicable.)

Access and Coverage: [Pharmacy plan: retail vs specialty] [Prior authorization needs] [Assistance programs] [Navigator involvement] [Pending lab follow-up: responsible party, timeframe, contingency] [Referrals as indicated: ID, hepatology, nephrology, behavioral health, substance use services]