PrEP-ared for Surgery? A Comprehensive Narrative Review of Perioperative Recommendations for Anesthesia Providers

Abstract

The use of Pre-Exposure Prophylaxis (PrEP) for human immunodeficiency virus (HIV) prevention has increased significantly, with approximately 30% of eligible individuals in the U.S. receiving a prescription by 2021, up from 13% in 2017. As more patients on PrEP undergo surgical procedures, understanding the perioperative implications of these medications is crucial for anesthesia providers. This review aims to summarize current literature on the perioperative considerations for patients on PrEP and provide anesthesia providers with key recommendations to optimize patient safety and outcomes. It examines the pharmacology, side effects, and perioperative considerations of current PrEP formulations: Truvada, Descovy, and Apretude. We conducted a broad literature search focusing on publications from 2013 through 2024. The review identifies potential nephrotoxicity with tenofovir-based formulations, particularly when combined with nephrotoxic agents such as nonsteroidal anti-inflammatory drugs. Emtricitabine/tenofovir alafenamide use is associated with an increased risk of hypertension and hypercholesterolemia. No specific anesthetic agents are contraindicated, but dose adjustments for renally excreted drugs may be necessary. Current evidence supports continuing PrEP throughout the perioperative period, with strategies provided for managing different formulations during surgery. As PrEP use expands, anesthesia providers must balance safe, effective care with contributing to HIV prevention efforts. Future research should focus on long-term anesthetic implications of PrEP and optimal perioperative management strategies. By implementing informed practices, anesthesia providers can significantly enhance the care of patients on PrEP and support broader public health goals in HIV prevention.

In 2021, more than 2 million people worldwide were newly infected with human immunodeficiency virus (HIV), including 36,136 individuals in the U.S. alone.¹ Additionally, it is estimated that approximately one in eight of the 1.2 million people living with HIV in the U.S. are unaware of their infection status.² This significant number of undiagnosed individuals poses a substantial risk for ongoing HIV transmission. One of the most effective strategies to mitigate this risk is the use of Pre-Exposure Prophylaxis (PrEP), a preventive intervention that has proved highly effective in reducing the likelihood of HIV transmission.

PrEP is the administration of antiretroviral medications to individuals without HIV to prevent the acquisition of the virus. The U.S. Food and Drug Administration (FDA) first approved a PrEP regimen in 2012 consisting of a fixed-dose combination tablet containing tenofovir disoproxil fumarate (TDF) 300 mg and emtricitabine 200 mg. That approval was aimed at addressing the preventative needs of individuals at high risk for HIV infection, including men who have sex with men, heterosexual men and women with multiple sexual partners and inconsistent condom use, and individuals who inject drugs and share needles.³ Oral PrEP is 99% effective in preventing HIV infection by sex and at least 74% effective when preventing HIV from drug injection, when taken as prescribed, and initiated at least 7 days before receptive anal sex and 21 days before receptive vaginal sex or intravenous (IV) drug use. Given this efficacy, PrEP is considered an essential tool in the U.S. Department of Health and Human Services efforts to reduce new HIV infections by 75% by 2025 and 90% by 2030.⁴

The use of PrEP has been steadily increasing, with approximately 30% of eligible individuals in the U.S. having a prescription in 2021, up from 13% in 2017.⁵ However, gaps persist in understanding its indications and perioperative implications for healthcare providers, particularly anesthesia providers. As the number of individuals undergoing surgical and anesthetic procedures rises, it is crucial for clinicians to understand the pharmacology, side effects, and potential drug interactions associated with available PrEP antiretrovirals in the perioperative setting.

While previous literature addressed the interactions between various antiretroviral medications and anesthetic drugs,⁶ the only previous scoping review of PrEP focused primarily on the study characteristics and topics of HIV PrEP literature and did not provide insight into the peri-operative considerations associated with the medication.⁷

This narrative review aims to deepen the understanding of PrEP medications among anesthesia providers, examine their implications within the perioperative setting, and identify areas requiring further research. By synthesizing the available literature and drawing on related knowledge about antiretroviral medications, we seek to provide practical guidance for anesthesia providers managing patients on PrEP in the perioperative period.

METHODS

Our initial approach to this review was a scoping review, but as we delved into the literature, it became clear that a narrative review would better serve our purpose of providing comprehensive insights for anesthesia providers. This approach allowed us to synthesize information from various sources, including pharmacologic data and clinical insights that might not be captured in a traditional scoping review.

We focused our exploration on four key questions:

1. How is the pharmacology of PrEP medications relevant to anesthesia practice?

2. How do PrEP medications interact with anesthetic agents and other perioperative medications?

3. What are the current recommendations for managing PrEP during the perioperative period?

4. How can anesthesia providers address barriers and stigma associated with PrEP use?

To answer these questions, we conducted a broad literature search using the databases EMBASE, PubMed, CINAHL, and Cochrane Review. We examined publications from 2013 (shortly after the FDA approval of PrEP) through 2024, using the keywords: preexposure prophylaxis, peri-operative care, HIV, antiretrovirals, and anesthesia. We included all article types (original research, commentaries, and review articles) that focused on adult patients and current PrEP medications. This inclusive strategy allowed us to incorporate not only empirical evidence but also expert perspectives and evolving clinical recommendations. We synthesized data from these diverse sources to construct a narrative that bridges the gap between HIV prevention literature and perioperative considerations. Our goal was to provide anesthesia providers with practical insights applicable to clinical practice.

During the screening process, we prioritized articles that directly addressed the perioperative considerations of PrEP use in clinical settings. We specifically included studies discussing PrEP pharmacology, its interactions with anesthetic agents and other perioperative medications, strategies for managing PrEP during the perioperative period, and the barriers and stigma associated with PrEP use in healthcare settings.

This focus ensured that our review remained clinically relevant to anesthesia providers by capturing key pharmacokinetic and pharmacodynamic properties of PrEP medications, their potential implications for anesthesia management, and practical guidelines for optimizing perioperative care.

Articles were included if they were peer-reviewed studies, review articles, or expert commentaries published between 2013 and 2024, focusing on adult patients (≥ 18 years) using current PrEP formulations. We selected studies that addressed PrEP pharmacology, perioperative management strategies, drug interactions, or anesthetic implications and were published in English. Articles were excluded if they solely explored HIV prevention strategies without specific relevance to anesthesia or perioperative care, focused exclusively on pediatric or adolescent populations, were non-English publications, or did not provide original data, clinical recommendations, or expert insights related to anesthesia and perioperative management. By applying these criteria, we ensured that the included literature was directly applicable to perioperative anesthesia practice, balancing empirical research with expert guidance to provide a comprehensive synthesis of current knowledge.

RESULTS

• Study Selection and Study Characteristics.

A total of 2,364 initial citations were identified, 2,187 titles and abstracts were screened, and 124 full text articles were reviewed by two reviewers. Six studies were included for this review (Figure). The articles included two meta-analyses, one systematic review, two delphi method, and one cohort design study (Table 1).

Figure.

PRISMA Diagram »

Table 1.

Perioperative Considerations for Patients Utilizing PrEP. Note: Articles listed alphabetically by first author. Abbreviations: PrEP, Preexposure prophylaxis; BMD, bone mineral density; TDF, tenofovir disoproxil furmarate; FTC, emticitabine; TAF, tenofovir alafenamide fumarate; CAB, cabotegravir; RTI, reverse transcriptase inhibitors; CBC, complete blood count; LFTs, liver function tests; BMP, basic metabolic panel; HbA1C; hemoglobin A1c; RCTs, randomized controlled trials; NSAIDs, non-steroidal anti-inflammatory drugs. »

Study Design	Sample	Medication	Outcome studied	Findings
Baranek et al8–The effect of TDF on bone mineral density: A systematic review and meta-analysis.
Meta-analysis	Randomized controlled trials	TDF/FTC	BMD Risk of osteoporosis Low bone mass and fractures	TDF was not associated with increased fractures compared with no PrEP TDF was associated with greater decrease in BMD, and increased risk of osteoporosis and low bone mass
Chou et al9–Preexposure prophylaxis for the prevention of HIV: Updated evidence report and systematic review for the U.S. preventive services task force.
Systematic review	Radomized controlled trials	TDF/FTC TAF/FTC CAB	HIV acquisition Mortality Harms Diagnostic test accuracy	PrEP was associated with reduced risk of incident HIV infection vs placebo or no PrEP PrEP was effective across population subgroups defined by HIV risk category There was no difference between oral prep with TDF alone or TDF/FTC vs placebo in risk of serious events Oral PrEP was associated with increased risk of kidney adverse events (primarily greater elevation in serum creatine level) and gastrointestinal adverse events (primarily nausea) There was no difference between TAF/FTC vs TDF/FTC in risk of serious adverse events
Rivera et al10–Use of TAF for HIV preexposure prophylaxis and incidence of hypertension and initiation of statins.
Cohort	N = 6824 Mean age: 33.9 years	TAF TDF	Hypertension Statin initiation	TAF use was found to be associated with higher incident hypertension and statin initiation compared with TDF, particularly in those ≥ 40 years
Russell et al11–Preoperative management of medications for rheumatologic and HIV diseases: Society for Perioperative Assessment and Quality Improvement consensus statement.
Delphi method	Consensus statement	TAF TAF/FTC TDF/FTC	Preoperative considerations	RTIs have few significant medication interactions and do not interact with the hepatic cytochrome P450 system Dosage reduction indicated if impaired postoperative kidney function Continue preoperatively, consider CBC with differential, LFTs, BMP, creatinine clearance, HbA1C when admitted and monitor CBC perioperatively
Schaefer et al12–Kidney function in TDF-based oral preexposure prophylaxis users: a systematic review and meta-analysis of published literature and a multi-country meta-analysis of individual participant data.
Delphi method	Randomized controlled trials or cohort studies	TDF TDF/FTC	Creatinine clearance	RCTs suggest kidney-related adverse events among TDF-based oral PrEP users are increased but generally mild Kidney function screening and monitoring should focus on older individuals, those with baseline creatinine clearance of less than 90 mL/min, and those with kidney-related comorbidities
Yan et al13–Perioperative care in adults with HIV.
Delphi method	Consensus statement	TDF TDF/FTC	Perioperative considerations	Antiretroviral therapies interruptions in the pre- and postoperative period should be avoided NSAIDs are not absolutely contraindicated in patients on TDF-based therapy; NSAIDs may increase the risk of impaired renal function in patents taking high doses of these medications, particularly in patients predisposed to renal dysfunction

• Pharmacology of Current Antiretrovirals Utilized for PrEP.

Three PrEP formulations (Table 2), Truvada (emtricitabine/tenofovir disoproxil fumarate), Descovy (emtricitabine/tenofovir alafenamide), and Apretude (cabotegravir) are currently commercially available for prevention of HIV transmission, including two daily oral medications and one bimonthly intramuscular injection option.¹⁷

Table 2.

Medications Utilized for Preexposure Prophylaxis for HIV. aAfter two monthly loading doses. Abbreviations: HIV, human immunodeficiency virus; TDF, tenofovir disoproxil fumarate; CBC, complete blood count; LFT, liver function test; BMP, basic metabolic panel; NSAIDs, nonsteroidal anti-inflammatory drugs; TAF, tenofovir alafenamide; CAB, cabotegravir. »

Brand Name	Route/ Frequency	HIV Testing Frequency	Preoperative Screening and Laboratory Monitoring	Anesthesia-Related and Pharmacologic Interactions
Truvada14 (TDF)	Oral/daily	Every three months	Creatinine clearance CBC LFTs BMP	NSAIDs may increase risk of renal impairment Risk of nephrotoxicity, potential accumulation of anesthetics in patents with renal impairment
Descovy15 (TAF)	Oral/daily	Every three months	Monitor blood pressure lipid profile Creatinine clearance	Hypertension Consider increased cardiovascular monitoring
Apretude16 (CAB)	Intramuscular/every 2 monthsa	Every two months	Monitor renal function CBC LFTs	Potential bleeding with antiplatelet agents at injection sites

• Truvada (Emtricitabine/Tenofovir Disoproxil Fumarate).

Truvada, which consists of emtricitabine and TDF, is widely used as a prophylactic measure for individuals at risk of HIV infection through sexual contact or injection drug use. The availability of generic versions further broadens its accessibility. Emtricibtabine (FTC) and TDF, are nucleoside analog reverse transcriptase inhibitors (NRTIs) which must be taken up into cells and sequentially phosphorylated in the cell to the pharmacologically active diphosphate and triphosphate anabolites to exert effect. Once in their active form, NRTIs block reverse transcriptase, the method by which HIV replicates (converting its RNA into DNA).¹⁷

The pharmacokinetics of FTC and TDF are important considerations for their efficacy as PrEP medications. FTC has a plasma half-life of approximately 10 hours, while tenofovir (the active form of TDF) has a plasma half-life of about 17 hours. However, the intracellular half-lives of their active metabolites are much longer: the half-life of FTC-triphosphate is about 39 hours, and that of tenofovir-diphosphate is approximately 150 to 180 hours in peripheral blood mononuclear cells. FTC reaches peak plasma concentrations within 1 to 2 hours after oral administration, while TDF reaches peak plasma levels within 30 minutes to 1 hour.¹⁸

The efficacy of these medications is therefore dependent on their intracellular half-life,¹⁹ with longer anabolite half-lives enabling less frequent dosing. The half-lives of tenofovir and emtricibtabine are the longest for the NRTI class,²⁰ which is a favorable pharmacologic characteristic for PrEP from an adherence perspective. In fact, while FTC and TDF are prescribed as a one tablet daily dose, there is theoretical effectiveness during periods of missed doses.¹⁹ However, these extended half-lives can also increase the risk of potentially harmful toxicities and drug and food interactions.

The side effects associated with FTC and TDF are generally mild but can include gastrointestinal symptoms such as nausea and diarrhea, headaches, and dizziness.¹⁹ In rare cases, TDF can cause renal toxicity and bone mineral density loss, which necessitates monitoring in certain populations, such as those with preexisting renal conditions or risk factors for osteoporosis. FTC is generally well tolerated but can occasionally cause skin hyper-pigmentation and mild gastrointestinal disturbances.

Given the potential impact of TDF on bone health, anesthesia providers should be aware of these risks in the perioperative setting. It is advisable to inquire about a patient’s history of osteoporosis or low bone mass when taking a medical history from patients on TDF-containing PrEP regimens. This information is particularly crucial when considering patient positioning and movement during surgery and postoperative care. Patients with a history of osteoporosis or those who have been on TDF for an extended period may be at increased risk for fractures during patient transfers or positioning. Anesthesia providers should exercise caution and ensure proper support and careful handling of these patients to minimize the risk of fractures or other bone-related complications. Additionally, this information should be communicated to the entire perioperative team to ensure consistent and careful patient handling throughout the perioperative period.²¹

• Descoy (Emtricitabine/Tenofovir Alafenamide).

Descovy is composed of a combination of emtricitabine and tenofovir alafenamide (TAF). TAF is a prodrug of tenofovir that is metabolized intracellularly into its active form, tenofovir diphosphate.²² This active metabolite inhibits the activity of reverse transcriptase, an enzyme critical for the replication of HIV. By blocking this enzyme, TAF prevents the virus from converting its RNA into DNA and integrating it into the host cell’s genome.²³ TAF is characterized by its ability to achieve effective intracellular concentrations at lower doses compared with its predecessor, TDF. This is due to its increased stability and more targeted delivery, which results in a reduced risk of systemic side effects and improved renal and bone safety profiles. TAF is absorbed after oral administration and reaches peak plasma concentrations within 1 to 2 hours. It is then metabolized by esterases and converted to TFV in the liver, where it is subsequently phosphorylated to its active form within cells. TAF’s enhanced intracellular delivery allows for effective suppression of HIV replication at lower doses, which minimizes systemic exposure and related adverse effects.²²

TAF is generally well tolerated, but it can have some side effects, albeit usually less severe than those associated with its predecessor, TDF.²³ Common gastrointestinal side effects include nausea, diarrhea, and abdominal pain which are generally mild to moderate. Renal effects are rare but can occur, particularly in individuals with preexisting kidney conditions or those on other nephrotoxic drugs. TAF is associated with less bone mineral density loss compared with TDF, although some users may still experience mild reductions in bone density. TAF use was also associated with an increased risk of hyper-tension and hypercholesterolemia.

• Apretude (Cabotegravir).

Apretude (consisting of cabotegravir) is a long-acting injectable form of PrEP. Cabotegravir (CAB) is an antiretroviral medication classified as an integrase strand transfer inhibitor, rather than a NRTI.²⁴ It is administered as a long-acting injectable formulation, typically dosed bimonthly following an initial loading period.

The loading period for Apretude is crucial for achieving and maintaining protective drug levels. The recommended dosing schedule begins with an initial 600 mg (3 mL) intramuscular injection of CAB at month 0, followed by a second 600 mg (3 mL) injection at month 1. After these initial loading doses, maintenance dosing consists of a 600 mg (3 mL) injection every 2 months. This loading period ensures that adequate drug concentrations are reached before transitioning to the less frequent maintenance dosing. It is important to note that if an injection is missed or delayed by more than 7 days, oral cabotegravir (30 mg tablet once daily) should be taken until the injection can be administered to maintain adequate protection.²⁵

This long-acting medication offers a convenient alternative to daily oral PrEP medications by requiring less frequent dosing, which can improve adherence and reduce the risk of missed doses.^26,27 CAB is considered more efficacious than oral PrEP options like tenofovir/emtricitabine due to its extended dosing interval, which maintains more consistent drug levels in the body and potentially provides better protection against HIV infection.²⁷ Additionally, its injectable form eliminates the need for daily pill-taking, which can be a barrier for some individuals.

The side effect profile of CAB includes common adverse events such as injection site reactions, including pain or swelling. Other potential side effects may include headache, fever, fatigue, and gastrointestinal symptoms such as nausea or diarrhea.^24,28 Despite these side effects, many patients tolerate the medication well. The advantages of reduced dosing frequency and higher adherence rates generally outweigh the discomfort associated with injections.

• On-Demand PrEP: An Alternative Dosing Strategy.

Although not approved by the FDA or Centers for Disease Control,²² on-demand oral PrEP with FTC/TDF (also known as non-daily PrEP, event-driven PrEP, or 2-1-1 PrEP) is an alternative dosing strategy.²⁹ This regimen is particularly useful for individuals who do not have frequent sexual encounters or who prefer not to take a daily medication. The process begins with an initial loading dose of two pills taken between 2 and 24 hours before the anticipated sexual activity, with the maximum efficacy generally achieved closer to the 24-hour mark. Following the initial dose, an additional pill should be taken 24 hours later, and then another pill 24 hours after that, totaling a three-dose regimen. This approach helps to maintain protective drug levels in the body around the time of potential HIV exposure and for the necessary period afterward.³⁰ Although studies have demonstrated that the dosing strategy has a similar rate of protection against HIV,^31,32 on-demand PrEP has higher rates of gastrointestinal and renal adverse events.

• Pharmacologic Interactions With Anesthesia and Perioperative Medications.

Formulations of PrEP containing tenofovir put patients at risk for nephrotoxicity. When concentrated in proximal renal tubular cells, tenofovir interferes with mitochondrial DNA synthesis resulting in metabolic perturbations and loss of cellular function and potentially Fanconi syndrome or type IV renal tubular acidosis.³³ Tenofovir nephrotoxicity is largely reversible, but the use of the medication is contraindicated in patients with a creatinine clearance < 60 mL/min and renal function is monitored at least once every 3 months on initiation. A meta-analysis demonstrated that the risk of kidney-related adverse events among TDF-based oral PrEP users are increased but generally mild.¹² Other nephrotoxic agents and nonsteroidal anti-inflammatory drugs (NSAIDs) are not absolutely contraindicated, but they may increase the risk of renal impairment and should be used cautiously, particularly in patients pre-disposed to renal dysfunction.¹³ This includes patients older than 40 years who have had longer duration of TDF use, and who have lower baseline renal function at the time of initiation of TDF.³⁶

Most studies on TDF were conducted over a period of no longer than 36 months. Given the potential for cumulative renal toxicity, further research is needed to explore the extended use of TDF and its impact on renal health. Further research to demonstrate the long-term effects of TDF on renal function, particularly in the setting of concomitant administration of nephrotoxic agents, is warranted.

In a cohort study involving 6,824 eligible participants without preexisting hypertension,¹⁰ the use of TAF as part of PrEP was associated with an increased risk of developing hypertension. Additionally, the study found that TAF use was linked to the initiation of statin therapy in PrEP users who had no prior history of statin use, indicating a potential increased risk of individuals ≥ 40 years old. These findings suggest that regular monitoring of blood pressure and lipid levels is essential for patients using TAF as part of their PrEP regimen to manage potential cardiovascular risk factors effectively.

• PrEP Administration in the Perioperative Period.

The efficacy of FTC/TDF for PrEP is closely related to patient adherence. PrEP should be continued for as long as an individual remains at high risk for HIV infection.^13,35,36 Interruptions in PrEP use should be avoided, as they increase the risk of HIV infection and the potential for rapid development of resistance to the medication. Since FTC/TDF can be taken with or without food, preoperative fasting does not affect its administration. If PrEP is discontinued for an extended period, HIV testing is recommended before resuming, particularly if any high-risk behaviors occurred during the break, to prevent the emergence of drug resistance.³⁷

• Barriers and Stigma Associated With PrEP.

PrEP is an HIV medication and may be mistaken by providers to be the same medication taken by HIV-positive individuals leading to stigmatization by association. Both potential and current PrEP users report concerns that others will think that they are HIV-positive if they are seen taking PrEP.^38,39 Patients may not report they are using PrEP because of these concerns. Furthermore, stigma may also arise from moral or cultural attitudes and beliefs about risk behaviors and the character of those who engage in them.⁴⁰ PrEP users may also face difficulty with respect to obtaining insurance and employment given the association with risk behaviors.⁴⁰

DISCUSSION

The peer-reviewed PrEP literature has rapidly increased since the FDA approval for usage in 2012, reflecting its growing acceptance and utilization as a preventive measure against HIV. Despite this, there remains a notable gap in the literature concerning the use of PrEP in patients undergoing surgery. Addressing this gap in research is essential for developing comprehensive guidelines for the management of PrEP in surgical patients, ensuring they remain protected from HIV even during perioperative periods. This review aims to address this gap and provide anesthesia providers with the necessary insights for managing these patients effectively.

• Pharmacologic Considerations and Drug Interactions.

While no specific anesthetic medications are contraindicated for patients on PrEP, several important considerations arise. Tenofovir-based formulations (TDF and TAF) carry a risk of nephrotoxicity, particularly when combined with other nephrotoxic agents such as NSAIDs.³³ Anesthesia providers should consider adjusting doses of renally-excreted anesthetic drugs, such as rocuronium, for patients on TDF or TAF. Additionally, drugs competing for renal tubular secretion (i.e., like probenecid) may increase tenofovir levels and should be used cautiously.

Cardiovascular considerations are also significant for patients on TAF, which may increase the risk of hypertension and hyperlipidemia.¹⁰ Closer intraoperative blood pressure monitoring is advised for these patients. Although PrEP medications are primarily excreted renally, potential interactions with anesthetics metabolized by the liver also warrant attention.

• Perioperative Management.

As anesthesia providers, we play a crucial role in maintaining the continuity of PrEP therapy during the perioperative period. Our review found no evidence supporting the discontinuation of PrEP during surgery, and expert recommendations suggest continuing PrEP throughout this time unless specifically contraindicated.^13,36,37 However, the practical aspects of managing PrEP in surgical patients require careful consideration and planning. Table 3 summarizes the perioperative considerations for anesthesia providers.

Table 3.

Summary of Best Practices for Anesthesia Providers in Patients Utilizing PrEP. Abbreviations: PrEP, preexposure prophylaxis; HIV, human immunodeficiency virus; TDF, tenofovir disoproxil fumarate; TAF, tenofovir alafenamide; CAB, cabotegravir; NSAIDs, nonsteroidal anti-inflammatory drugs. »

Clinical Focus Area	Recommendations
Perioperative assessment and risk evaluation	Routinely ask about PrEP use during preoperative evaluations. Review recent renal function tests, particularly for patients on TDF or TAF.14 Assess cardiovascular risk factors, especially in patients > 40 years or those on TAf.15 nquire about bone health history, especially in patients on long-term TDF.14
Medication management and continuity of PrEP	Ensure continuation of PrEP throughout the perioperative period unless contraindicated. Allow oral PrEP with a sip of water on day of surgery, even during fasting periods. Coordinate injection timing for patients on long-acting CAB with HIV care providers.16
Anesthetic planning & drug interactions	Consider potential interactions between PrEP and anesthetic agents when planning anesthetic management. Monitor renal function and electrolyte balance closely during and after surgery, especially with TDF or TAF.14,15 Consider adjusting doses of renally-excreted anesthetic drugs, such as rocuronium, for patients on TDF or TAF.14,15
Pain management and regional anesthesia	Minimize NSAID use in patients with renal impairment and opt for alternatives where possible. Be cautious of regional anesthesia near CAB injection sites due to potential local reactions.16
Patient handling and communication	Take extra care with positioning and transfers in patients on long-term TDF due to bone density risks.14 Ensure the perioperative team is informed of the patient’s PrEP use. Foster nonjudgmental, open conversations to encourage PrEP disclosure and reduce stigma.
Postoperative care and follow-up	Provide clear instructions on resuming or continuing PrEP postsurgery. Ensure follow-up for renal function monitoring if nephrotoxic agents were used during the perioperative period.
Education and provider training	Stay updated on PrEP medications and their potential perioperative implications. Promote education on PrEP to reduce stigma and improve patient care across the anesthesia team.

The perioperative journey for a patient on PrEP begins with the preoperative evaluation, and, it is essential to confirm the patient’s PrEP regimen, including the type of medication and dosing schedule. For patients on oral PrEP such as TDF/FTC or TAF/FTC, the timing of their daily dose in relation to the surgery should be considered. If the procedure is scheduled for the morning, the patient can be advised to take their dose with a small sip of water upon waking, even during fasting periods. For afternoon surgeries, it is best to administer the dose at least 2 hours prior the procedure, again with minimal water.

The situation becomes more complex for patients on long-acting injectable CAB. If an injection is due within a week of the surgery, it is crucial to coordinate with the patient’s primary care provider. In cases where an injection coincides with the day of surgery, we typically recommend administering it postoperatively to avoid any potential complications.

When moving into the operating room, clear communication with the surgical team about the patients PrEP status becomes paramount. For surgeries lasting more than 6 hours, consultation with an HIV specialist may be warranted about the potential need for an additional dose, particularly for patients on oral PrEP. The specialist’s input can help tailor the management plan, considering factors such as the timing of the patient’s last dose, their renal function, and the specifics of the surgery. Close coordination among the surgical, anesthesia, and infectious disease teams ensures that the patient’s HIV prevention strategy is maintained without compromising their overall perioperative care.

The postoperative period presents its own set of challenges. Our goal is to resume oral PrEP as soon as the patient can tolerate oral medications, ideally within 24 hours postsurgery. However, if a patient cannot take oral medications for an extended period, alternative strategies should be prepared. This might involve consulting an HIV specialist about alternative administration routes, such as using a nasogastric tube, or even considering a temporary switch to injectable PrEP (CAB).

Special consideration should be given to patients on “on-demand” or “2-1-1” PrEP regimens. These cases often require consultation with an HIV specialist to develop a perioperative plan that maintains protective drug levels while accommodating the surgical schedule. Throughout the perioperative process, clear documentation is crucial. PrEP administration should be recorded in the perioperative record and ensure that discharge instructions include guidance on resuming or continuing PrEP. It is also beneficial to recommend a follow-up with the patient’s primary care provider within 1-2 weeks postsurgery to assess PrEP adherence and address any potential complications.

While these strategies provide a framework for managing PrEP in the perioperative setting, it is important to note that the literature specifically addressing this topic is limited. As such, we must remain flexible in our approach and adapting these recommendations based on individual patient factors and always being ready to consult with HIV specialists when faced with complex cases. By taking a proactive and informed approach to PrEP management in surgical patients, we as anesthesia providers can significantly contribute to maintaining effective HIV prevention, even in the challenging context of perioperative care.

• Pain Management and Regional Anesthesia.

NSAID medication use for perioperative pain management should be approached with caution, particularly in patients with any signs of renal impairment. Alternative pain management strategies or reduced NSAID doses should be considered when possible. For regional anesthesia, patients on CAB may experience injection site reactions, necessitating care when performing regional blocks near recent injection sites.

• Reducing Barriers and Stigma.

An essential aspect of care is addressing the stigma associated with PrEP. Previous studies have described patients avoiding disclosing their PrEP use to others to avoid being stigmatized and the stigma associated with the utilization of PrEP including presumed promiscuity, sexual orientation, and gender identity.³⁹ Clinicians should foster a welcoming environment that encourages open communication, allowing for comprehensive perioperative planning. Appropriate sensitivity without judgment or assumption about reasons for use should be used when asking patients about PrEP use because individuals who perceive a supportive social environment regarding PrEP are more likely to feel at ease discussing it with their healthcare provider.^41-43 Furthermore, PrEP-related stigma, including misconceptions about its effectiveness, concerns about judgment, and fears of being labeled as promiscuous or engaging in risky behavior, can deter individuals from seeking information and engaging in open conversations with their healthcare providers and may lead to patients not reporting use during the perioperative period. By dispelling stigma and providing PrEP-competent care, anesthesia providers can contribute to the national strategy of reducing new HIV infections.

• Strategies for Anesthesia Providers to Improve Communication.

To integrate awareness of PrEP-related stigma into the preoperative consultation process and create a more welcoming environment, anesthesia providers can use several strategies. Standardizing medication inquiries by including PrEP alongside other common medications in preoperative questionnaires helps normalize its discussion. Using inclusive language, such as utilizing gender-neutral terms and avoiding assumptions about sexual orientation or behavior when discussing sexual health, is crucial. Providers should ensure conversations about medications and sexual health occur in a private setting to promote openness. Regular staff education through training sessions on PrEP, its importance, and strategies for nonstigmatizing communication is essential. Displaying inclusive materials, such as informational posters about PrEP and HIV prevention in waiting areas, signals openness to discussing these topics. Practicing active listening by giving patients ample opportunity to express concerns without interruption or judgment is vital. Providers should also offer reassurance by emphasizing the importance of knowing all medications for safe anesthesia care, regardless of the reason for taking them. By implementing these strategies and using nonstigmatizing language, anesthesia providers can create an environment where patients feel comfortable disclosing their PrEP use, leading to more comprehensive and effective perioperative care.

CONCLUSION

The growing use of PrEP presents unique considerations for anesthesia providers. This review highlights the importance of understanding PrEP pharmacology, potential drug interactions, and perioperative management strategies. While no specific anesthetic agents are contraindicated, careful attention should be given to renal function, cardiovascular status, and drug interactions, especially with tenofovir-based formulations. Current evidence supports continuing PrEP perioperatively, highlighting the need for anesthesia providers to facilitate medication adherence. Addressing stigma and creating a supportive environment for PrEP disclosure is essential for comprehensive care. Future research should focus on long-term anesthetic implications of PrEP and optimal perioperative management strategies. By implementing informed practices, anesthesia providers can significantly enhance the care of patients on PrEP and support broader public health goals.