12.1 Sexual Health Counseling & Risk-Reduction Strategies

ABFM Family Medicine Certification Study Guide Exam

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1 Chapter 1: Exam Structure, Blueprint & Clinical Decision-Making

1.1 Exam Blueprint, FMCLA vs. One-Day Exam & Board Scoring 1.2 Clinical Reasoning, Test-Taking Strategy & Ambiguity Management 1.3 Evidence-Based Medicine & Clinical Practice Guidelines in Primary Care

2 Chapter 2: Healthcare Systems, Practice Management & Quality

2.1 Practice Management, Billing, Coding & Documentation 2.2 Quality Improvement, Patient Safety & Diagnostic Stewardship 2.3 Interprofessional Team-Based Care & Care Coordination

3 Chapter 3: Ethics, Law, Biostatistics & Health Equity

3.1 Medical Ethics, Informed Consent & Surrogate Decision-Making 3.2 Biostatistics, Clinical Epidemiology & Diagnostic Test Interpretation 3.3 Social Determinants of Health, Health Equity & Cultural Humility 3.4 Physician Wellness, Burnout Prevention & Professionalism

4 Chapter 4: Lifestyle Counseling & Behavior Change

4.1 Alcohol Use Screening & Brief Intervention 4.2 Illicit Drug & Cannabis Counseling 4.3 Tobacco & Vaping Cessation Counseling

5 Chapter 5: Nutrition, Physical Activity & Chronic Disease Prevention

5.1 Dietary Counseling for Obesity & Chronic Disease Prevention 5.2 Exercise Prescription & Physical Activity Counseling 5.3 Genetic Risk Assessment & Family History Counseling

6 Chapter 6: Routine Adult Immunizations

6.1 ACIP Adult Respiratory Vaccines: Influenza, COVID-19, RSV & Pneumococcal 6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B 6.3 Immunizations in Special Populations: Pregnancy, Asplenia & Immunocompromise

7 Chapter 7: Pediatric Health Maintenance & Surveillance

7.1 Newborn Examination & Early Postnatal Care 7.2 Well-Child Care, Developmental Surveillance & Milestones 7.3 Pediatric & Adolescent Screening: Vision, Hearing, Anemia & Lead 7.4 Pediatric Oral Health, Dental Screening & Fluoride

8 Chapter 8: Behavioral Health & Safety Screening

8.1 Primary Care Depression, Anxiety & Behavioral Health Screening 8.2 Domestic Violence, Intimate Partner Violence & Firearm Safety 8.3 Occupational Health & Recreational Safety Counseling

9 Chapter 9: Adult Preventive Screening: Cardiovascular & Metabolic

9.1 Cardiovascular Disease & Hypertension Screening 9.2 Type 2 Diabetes Screening & Prediabetes Risk Stratification 9.3 Abdominal Aortic Aneurysm & Osteoporosis Screening

10 Chapter 10: Adult Cancer Screening: Breast & Gynecologic

10.1 Breast Cancer Screening & Risk-Assessment 10.2 Cervical Cancer Screening & ASCCP Algorithms 10.3 Skin Cancer Clinical Assessment & Counseling

11 Chapter 11: Adult Cancer Screening: Colorectal, Lung & Prostate

11.1 Colorectal Cancer Screening Modalities & Intervals 11.2 Lung Cancer Screening with Low-Dose CT 11.3 Prostate Cancer Screening & Shared Decision-Making

12 Chapter 12: Sexual Health, Infectious Disease Screening & Contraception

12.1 Sexual Health Counseling & Risk-Reduction Strategies 12.2 STI Screening: Chlamydia, Gonorrhea, Syphilis & Trichomoniasis 12.3 Bloodborne Infectious Disease Screening: HIV & Hepatitis C

13 Chapter 13: Reproductive Life Planning, Lactation & Preoperative Care

13.1 Preconception Planning & Comprehensive Contraception Management 13.2 Lactation Support & Breastfeeding Counseling 13.3 Preoperative Medical Evaluation & Pre-Participation Sports Exam

14 Chapter 14: Emergent Cardiovascular Conditions

14.1 Acute Coronary Syndromes & Myocardial Infarction 14.2 Acute Chest Pain Risk Stratification & Triage 14.3 Acute or Critical Valvular Heart Emergencies

15 Chapter 15: Cardiac Arrhythmias, Heart Failure & Hypertensive Crises

15.1 Acute Atrial & Ventricular Arrhythmias 15.2 Acute Decompensated Heart Failure & Cardiogenic Shock 15.3 Hypertensive Emergency & Urgency Management

16 Chapter 16: Vascular & Thromboembolic Emergencies

16.1 Pulmonary Embolism & Deep Vein Thrombosis 16.2 Acute Aortic Syndromes & Peripheral Vascular Emergencies 16.3 Critical Limb Ischemia & Acute Arterial Occlusion

17 Chapter 17: Neurologic Emergencies: Stroke & Altered Consciousness

17.1 Acute Ischemic Stroke & Intracranial Hemorrhage 17.2 Syncope Evaluation & Status Epilepticus 17.3 Acute Delirium, Encephalopathy & Severe Confusion

18 Chapter 18: Neurologic Trauma & Acute Cranial Emergencies

18.1 Concussion, Moderate-to-Severe TBI & Intracranial Injury 18.2 Thunderclap & Acute Severe Secondary Headaches 18.3 Acute Ophthalmologic Emergencies

19 Chapter 19: Acute Abdominal, Pelvic & Gastrointestinal Emergencies

19.1 Acute Abdominal & Pelvic Pain Triage 19.2 Upper & Lower Gastrointestinal Bleeding 19.3 Acute Hepatic Failure, Cholangitis & Severe Jaundice

20 Chapter 20: Acute Pulmonary & Airway Emergencies

20.1 Acute Hypoxic Respiratory Failure & ARDS 20.2 Severe Community-Acquired Pneumonia & Empyema 20.3 Acute Severe Epistaxis & Airway Obstruction

21 Chapter 21: Acute Traumatic Injuries & Wound Care

21.1 Major Trauma Resuscitation & Initial Assessment 21.2 Burn Assessment, Inhalation Injury & Resuscitation 21.3 Laceration Management, Complex Wounds & Animal Bites

22 Chapter 22: Acute Orthopedic & Musculoskeletal Emergencies

22.1 Acute Ambulatory Fractures & Initial Splinting 22.2 Compartment Syndrome & Major Orthopedic Trauma 22.3 Septic Arthritis & Acute Microcrystalline Crises

23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

23.1 Sepsis, Septic Shock & Initial Fluid Resuscitation 23.2 Necrotizing Soft Tissue Infections & Severe CNS Infections 23.3 Anaphylaxis Diagnosis, Epinephrine Dosing & Airway Protection

24 Chapter 24: Metabolic, Endocrine & Electrolyte Emergencies

24.1 Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State 24.2 Critical Electrolyte Emergencies: Dyskalemias & Dysnatremias 24.3 Severe Calcium Abnormalities & Acute Adrenal Crisis

25 Chapter 25: Hematologic, Urologic & Dental Emergencies

25.1 Severe Symptomatic Anemias & Coagulopathic Emergencies 25.2 Testicular Torsion, Priapism & Acute Urinary Retention 25.3 Urgent Odontogenic Infections & Dental Trauma

26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

26.1 Suicidal Ideation, Acute Agitation & Behavioral Emergencies 26.2 Acute Physical & Sexual Assault Care 26.3 Life-Threatening Vaginal Bleeding & Ectopic Pregnancy 26.4 Environmental Heat Stroke & Severe Hypothermia

27 Chapter 27: Acute Head, Neck & Neurologic Symptoms

27.1 Primary Acute Headaches: Migraine, Tension & Cluster 27.2 Concussion & Minor Closed Head Injury Evaluation 27.3 Transient Ischemic Attack Evaluation & ABCD2 Risk Scoring

28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

28.1 Peripheral Neuropathies: Bell's Palsy, Carpal Tunnel & Radiculopathy 28.2 Acute Tinnitus, Sudden Sensorineural Hearing Loss & Cerumen Impaction 28.3 Acute Dizziness, Benign Paroxysmal Positional Vertigo & Vestibular Neuritis

29 Chapter 29: Acute Upper Respiratory Tract Infections

29.1 Acute Viral Rhinosinusitis vs. Bacterial Rhinosinusitis 29.2 Acute Pharyngitis: Group A Streptococcus & Centor Criteria 29.3 Acute Otitis Media, Otitis Externa & Serous Effusion

30 Chapter 30: Acute Lower Respiratory Infections & Cough

30.1 Influenza, COVID-19 & Viral Respiratory Syndromes 30.2 Acute Bronchitis & Lower Respiratory Tract Infections 30.3 Ambulatory Community-Acquired Pneumonia

31 Chapter 31: Allergic, Nasal & Non-Infectious Pulmonary Conditions

31.1 Allergic Rhinitis & Acute Non-Anaphylactic Allergic Reactions 31.2 Acute Dyspnea in Ambulatory Care 31.3 Interstitial Lung Diseases & Sarcoidosis Presentation

32 Chapter 32: Acute Chest, Cardiac & Vascular Symptoms

32.1 Palpitations Evaluation & Arrhythmia Triage in Primary Care 32.2 Deep Vein Thrombosis & Superficial Thrombophlebitis 32.3 Ambulatory Hypotension & Orthostasis Evaluation

33 Chapter 33: Acute Upper Gastrointestinal Conditions

33.1 Peptic Ulcer Disease & Gastritis 33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders 33.3 Acute Nausea, Vomiting & Foodborne Illness

34 Chapter 34: Acute Lower Gastrointestinal Conditions

34.1 Acute Infectious Diarrhea & Gastroenteritis 34.2 Acute Constipation & Functional Bowel Changes 34.3 Ano-Rectal Disorders: Hemorrhoids, Fissures, Abscesses & Pruritus Ani

35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

35.1 Acute Flares of Inflammatory Bowel Disease 35.2 Irritable Bowel Syndrome: Diagnosis, Subtyping & Management 35.3 Celiac Disease & Malabsorption Syndromes

36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

36.1 Ambulatory Abdominal & Pelvic Pain Triage 36.2 Acute Cholecystitis, Biliary Colic & Pancreatitis 36.3 Acute Liver Injury & Viral Hepatitis

37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

37.1 Abdominal Wall, Inguinal & Ventral Hernias 37.2 Acute Dental Pain, Odontogenic Abscess & Aphthous Ulcers 37.3 Acute Edema: Unilateral vs. Bilateral Diagnostic Evaluation

38 Chapter 38: Acute Infectious Dermatoses

38.1 Bacterial Skin Infections: Impetigo, Cellulitis & Cutaneous Abscesses 38.2 Fungal Skin Infections: Tinea Corporis, Cruris, Pedis & Onychomycosis 38.3 Viral Cutaneous Infections: Herpes Simplex, Zoster & Molluscum Contagiosum

39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

39.1 Atopic Dermatitis, Contact Dermatitis & Eczematous Flares 39.2 Non-Infectious Rashes: Urticaria, Drug Eruptions & Erythema Multiforme 39.3 Cutaneous Malignancies & Premalignant Lesions: AK, BCC, SCC & Melanoma

40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

40.1 Rotator Cuff Pathology, Tendinopathy & Shoulder Impingement 40.2 Lateral & Medial Epicondylitis, Olecranon Bursitis & Elbow Sprains 40.3 Wrist & Hand Soft-Tissue Injuries: De Quervain, TFCC & Finger Sprains

41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

44.1 Acute Inflammatory Arthritis & Spondyloarthropathies 44.2 Myalgias, Rhabdomyolysis & Post-Viral Pain Syndromes 44.3 Acute Non-Headache Pain Management Strategies

45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

45.1 Uncomplicated UTI, Pyelonephritis & Acute Urethritis 45.2 Hematuria Workup & Glomerulonephritis 45.3 Nephrolithiasis & Acute Urinary Tract Obstruction

46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

46.1 Acute Prostatitis, Epididymitis & Orchitis 46.2 Acute Scrotal Pain: Torsion vs Appendage, BPH & Male Genital Emergencies 46.3 Acute Urinary Retention & Incontinence Evaluation

47 Chapter 47: Acute Women's Health & Early Pregnancy Care

47.1 Early Pregnancy Diagnosis, Dating & Initial Complications 47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders 47.3 Premenstrual Syndrome & Premenstrual Dysphoric Disorder

48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

50.1 Essential Hypertension Management: 2025 AHA/ACC Guideline & JNC Strategies 50.2 Chronic Coronary Artery Disease & Post-MI Secondary Prevention 50.3 Chronic Heart Failure: HFrEF, HFpEF & Quadruple GDMT

51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

51.1 Peripheral Arterial Disease & Claudication 51.2 Chronic Valvular Heart Disease & Murmur Evaluation 51.3 Lipid Disorders & ASCVD Risk-Based Statin Therapy

52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

52.1 Chronic Asthma Management: GINA Stepwise SMART Therapy 52.2 Chronic Obstructive Pulmonary Disease: GOLD Recommendations 52.3 Solitary Pulmonary Nodule Evaluation & Fleischner Society Criteria

53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

53.1 Type 2 Diabetes Management: ADA Pharmacotherapy Algorithms 53.2 Type 1 Diabetes: Basal-Bolus Insulin, CGMs & Diabetic Complications 53.3 Diabetic Microvascular & Macrovascular Disease Surveillance

54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

54.1 Medical & Behavioral Management of Obesity & Incretin Mimetics 54.2 Osteoporosis & Metabolic Bone Disease: DEXA, FRAX & Antiresorptives 54.3 Nutritional Deficiencies: Vitamin D, B12, Iron & Malnutrition

55 Chapter 55: Chronic Endocrine Disorders

55.1 Primary & Subclinical Hypothyroidism, Hyperthyroidism & Nodules 55.2 Adrenal Disorders: Addison's Disease & Cushing's Syndrome 55.3 Hypercalcemia, Hyperparathyroidism & Pituitary Disorders

56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

12.1 Sexual Health Counseling & Risk-Reduction Strategies

Key Takeaways Explain This Topic AI

The CDC 5 P's framework (Partners, Practices, Protection from STIs, Past history of STIs, and Prevention of pregnancy / Pleasure) provides a structured, non-judgmental approach to taking a comprehensive sexual history in primary care.

The USPSTF issues a Grade A recommendation for prescribing HIV Pre-Exposure Prophylaxis (PrEP) to adolescents and adults at high risk of HIV acquisition; approved modalities include daily oral TDF/FTC, daily oral TAF/FTC, and bimonthly long-acting injectable cabotegravir.

Daily oral TAF/FTC (Descovy) is approved for individuals at risk through receptive anal sex and injection drug use, but is strictly NOT approved for individuals at risk through receptive vaginal sex due to the absence of clinical efficacy trial data in cisgender women.

Mandatory pre-PrEP laboratory evaluation requires documented negative HIV status within 7 to 14 days prior to prescription, serum creatinine/eGFR, hepatitis B serologies (HBsAg, anti-HBs, anti-HBc), and baseline multi-site STI screening; discontinuing TDF or TAF in patients with chronic HBV carries a severe risk of acute, life-threatening hepatic flares.

Post-Exposure Prophylaxis (PEP) must be initiated as soon as possible and within 72 hours of high-risk exposure as a 28-day course of a 3-drug antiretroviral regimen (TDF/FTC plus dolutegravir or raltegravir), followed by repeat HIV testing at 4 to 6 weeks and 12 weeks.

Last updated: September 2026

Comprehensive Sexual History: The CDC 5 P's Framework

A thorough, non-judgmental sexual history is fundamental to primary care preventive medicine. It identifies risks for sexually transmitted infections (STIs), human immunodeficiency virus (HIV), unplanned pregnancies, and sexual dysfunction. The Centers for Disease Control and Prevention (CDC) formalizes this assessment through the 5 P's framework :

Partners :

Inquiry : Assess the gender, biological sex, and number of sexual partners over defined time horizons (past 2 to 3 months and past 12 months).

Clinical Phrasing : "In the past 12 months, how many sexual partners have you had? Are your partners men, women, nonbinary individuals, or all of the above?"

Risk Stratification : Assess concurrent partnerships, partners with known HIV/STIs, or partners with injection drug exposure.

Practices :

Inquiry : Clarify specific sexual acts to guide anatomical site-specific screening (pharyngeal, urogenital, rectal).

Clinical Phrasing : "To help me decide which lab tests are appropriate, what specific sexual acts do you engage in? Do you engage in oral sex, vaginal sex, or anal sex? Are you the insertive partner, receptive partner, or both?"

Clinical Significance : More than 70% of extragenital gonococcal and chlamydial infections are asymptomatic and completely missed if clinicians only obtain urine samples.

Protection from STIs :

Inquiry : Determine the frequency and consistency of barrier method use.

Clinical Phrasing : "How often do you use barrier methods such as external condoms, internal condoms, or dental dams? Do you use them all the time, sometimes, or never? In what situations do you use protection?"

Harm Reduction : Inquire about lubricant use (water-based or silicone lubricants are compatible with latex; oil-based products compromise latex integrity, resulting in condom rupture).

Past History of STIs :

Inquiry : Document historical STI diagnoses, completed treatments, and recurrence patterns.

Clinical Phrasing : "Have you ever been diagnosed with or treated for a sexually transmitted infection such as chlamydia, gonorrhea, syphilis, herpes, trichomoniasis, or HPV? Has any partner notified you of an STI?"

Epidemiological Correlation : A prior bacterial STI within the preceding 6 to 12 months is one of the strongest independent clinical predictors of future STI acquisition and HIV seroconversion.

Prevention of Pregnancy / Pleasure :

Reproductive Life Plan : "Do you or your partner have plans or desire for pregnancy now or in the future? What methods are you currently using to prevent pregnancy?"

Dual Protection : Emphasize that highly effective reversible contraceptives (e.g., intrauterine devices, subdermal implants, oral contraceptives) provide zero protection against STIs and HIV; condoms must be combined with systemic contraception for comprehensive risk reduction.

Sexual Satisfaction & Pleasure : Assess sexual function, pain (dyspareunia), erectile dysfunction, libido, and lubrication. Clinicians should ensure discussions are sex-positive and trauma-informed.

LGBTQ+ Affirming Care & Inclusive Practice

Creating an affirming, clinically competent environment for lesbian, gay, bisexual, transgender, queer, and gender-diverse (LGBTQ+) patients is essential to eliminate health disparities and build therapeutic trust.

Inclusive Clinical Communication & Etiquette

Pronouns and Chosen Names : Standard intake paperwork and verbal introductions should invite patients to share their pronouns (e.g., she/her, he/him, they/them) and chosen name, which may differ from their legal name or electronic medical record identifier.

Neutral, Non-Heteronormative Language : Use open-ended phrasing. Ask "Are you in a relationship?" or "Do you have a partner or partners?" rather than presuming marital status, sexual orientation, or the gender of partners.

Organ Inventory Approach : In transgender and gender-diverse patients, clinicians must never make assumptions regarding anatomical structures based on gender presentation or identity. Conduct an explicit organ inventory : document the presence or absence of breasts, cervix, uterus, ovaries, prostate, testes, neovagina, or neopenis. Clinical screening rules follow anatomy: anyone with an intact cervix requires cervical cancer screening, and anyone with a prostate requires age-appropriate prostatic assessment.

Patient-Affirmed Terminology : Clarify terms the patient prefers for their genitalia during examinations (e.g., "external genitalia," "frontal opening," "chest tissue").

Gender-Affirming Hormone Therapy (GAHT) Considerations :

Masculinizing Therapy (Exogenous Testosterone) : Induces amenorrhea and endometrial atrophy but does not reliably suppress ovulation ; pregnancy can still occur. AFAB patients on testosterone engaging in penile-vaginal intercourse require effective non-estrogenic contraception (e.g., levonorgestrel IUD, copper IUD, depot medroxyprogesterone acetate, or etonogestrel subdermal implant).

Feminizing Therapy (Exogenous Estrogen + Antiandrogens) : Induces testicular atrophy and reduces spermatogenesis, but is not a reliable contraceptive . AMAB patients engaging in insertive sex with partners who can become pregnant must be counseled on barrier methods or partner contraception.

Drug-Drug Interactions with PrEP : Tenofovir disoproxil fumarate (TDF), tenofovir alafenamide (TAF), emtricitabine (FTC), and cabotegravir have no clinically significant pharmacokinetic interactions with feminizing (estradiol, spironolactone) or masculinizing (testosterone) gender-affirming regimens. Patients should be reassured that PrEP does not diminish the clinical efficacy or blood levels of their hormones.

HIV Pre-Exposure Prophylaxis (PrEP): USPSTF Grade A Recommendations

HIV Pre-Exposure Prophylaxis (PrEP) involves the administration of antiretroviral medications to HIV-negative individuals at high risk of HIV acquisition. The United States Preventive Services Task Force (USPSTF) issues a Grade A recommendation that clinicians offer PrEP with effective antiretroviral therapy to persons at high risk of HIV acquisition.

Clinical Indications for PrEP

According to CDC and USPSTF guidelines, PrEP is indicated for sexually active adolescents and adults (weight >=35 kg) and persons who inject drugs (PWID) meeting any of the following criteria within the preceding 6 months:

Men Who Have Sex with Men (MSM) and Transgender Women :

Any condomless anal sex (receptive or insertive) with a partner whose HIV status is unknown or positive (with a detectable or unknown viral load).

Diagnosis of a bacterial STI (chlamydia, gonorrhea, or syphilis) within the past 6 months.

Heterosexually Active Men and Women :

Condomless sex with a partner living with HIV who has a detectable or unknown viral load.

Inconsistent condom use with partners belonging to populations with high HIV prevalence (e.g., PWID, incarcerated persons, bisexual men).

Diagnosis of gonorrhea or syphilis within the past 6 months.

Persons Who Inject Drugs (PWID) :

Sharing of injection drug equipment, needles, syringes, cookers, or cotton.

Engaging in transactional sex or condomless sex alongside injection drug use.

FDA-Approved PrEP Regimens: Comparative Pharmacology

Currently, three antiretroviral regimens are FDA-approved for HIV pre-exposure prophylaxis in the United States:

Clinical Parameter Daily Oral TDF/FTC (Truvada) Daily Oral TAF/FTC (Descovy) Long-Acting Injectable Cabotegravir (Apretude)

Drug Class Dual NRTI combination Dual NRTI combination Second-Generation Integrase Strand Transfer Inhibitor (INSTI)

Components & Dosing Tenofovir disoproxil fumarate 300 mg / Emtricitabine 200 mg PO daily Tenofovir alafenamide 25 mg / Emtricitabine 200 mg PO daily Cabotegravir 600 mg (3 mL) intramuscular (IM) gluteal injection

Dosing Schedule Once daily oral tablet (or 2-1-1 event-driven in select MSM) Once daily oral tablet Month 1, Month 2 (loading), then every 2 months (every 8 weeks) thereafter

Approved Exposure Routes All sexual routes and PWID : Receptive/insertive anal, receptive/insertive vaginal, injection drug use Anal sex and PWID ONLY ; STRICTLY NOT approved for receptive vaginal sex All sexual routes : Receptive/insertive anal, receptive/insertive vaginal, PWID

Target Populations Cisgender men, cisgender women, transgender persons, PWID Cisgender MSM, transgender women, PWID Cisgender men, cisgender women, transgender persons, PWID

Renal Safety Threshold Requires baseline and maintained eGFR >=60 mL/min Requires baseline and maintained eGFR >=30 mL/min No renal cutoff (not nephrotoxic; preferred in renal impairment)

Bone & Renal Toxicity Profile Associated with proximal renal tubulopathy (Fanconi syndrome) and 1% to 2% decrease in bone mineral density (BMD) Significantly lower plasma tenofovir levels; superior renal and bone mineral density profile compared to TDF Zero renal tubular toxicity; zero bone mineral density reduction

Metabolic & Weight Effects Weight-neutral or mild weight loss; lipid-neutral or mild statin-like lipid lowering Associated with modest weight gain (1 to 2 kg) and mild increases in total cholesterol, LDL, and triglycerides Weight-neutral; minimal metabolic or lipid alterations

Time to Protective Tissue Levels ~7 days for receptive anal tissue; ~21 days for receptive vaginal tissue and blood (PWID) ~7 days for receptive anal tissue; (efficacy in vaginal tissue not established) Effective immediately following proper loading doses; sustained therapeutic levels

Clinical Deep-Dive: TDF/FTC vs. TAF/FTC

Tenofovir Disoproxil Fumarate (TDF) is an acyclic nucleotide diester prodrug. Following oral ingestion, TDF is rapidly cleaved in plasma into free tenofovir, resulting in high circulating systemic tenofovir concentrations before intracellular entry. This high circulating load interacts with organic anion transporters (OAT1/OAT3) in the renal proximal convoluted tubule, potentially inducing mitochondrial DNA depletion, proximal tubular dysfunction (Fanconi syndrome with glucosuria, phosphaturia, aminoaciduria), and accelerated bone mineral turnover.

Tenofovir Alafenamide (TAF) is a targeted phosphonamidate prodrug. TAF remains intact and highly stable in systemic circulation, resulting in >90% lower plasma tenofovir concentrations while delivering 4- to 7-fold higher intracellular active tenofovir diphosphate concentrations within target peripheral blood mononuclear cells (PBMCs) and lymphoid tissue. This translates into minimal nephrotoxicity and preservation of bone mineral density.

CRITICAL BOARD EXAM PEARL: The Receptive Vaginal Exclusion for TAF/FTC : The landmark Phase 3 DISCOVER trial evaluated the non-inferiority of TAF/FTC compared to TDF/FTC exclusively in cisgender MSM and transgender women having condomless receptive anal intercourse. The trial explicitly did not enroll cisgender women or individuals engaging in receptive vaginal sex . Furthermore, pharmacokinetic studies indicate that active tenofovir diphosphate concentrations in cervical and vaginal mucosal tissues are markedly lower with TAF than with TDF. Consequently, TAF/FTC (Descovy) is NOT FDA-approved or guideline-endorsed for individuals at risk of HIV acquisition through receptive vaginal intercourse . In a cisgender female seeking oral PrEP, TDF/FTC (Truvada) is the only approved oral regimen !

Long-Acting Injectable Cabotegravir (Apretude)

Mechanism : Long-acting formulation of cabotegravir, an integrase strand transfer inhibitor (INSTI) that binds the integrase active site, blocking the strand transfer step of retroviral DNA integration into host chromatin.

Administration : Administered as a 600-mg (3-mL) deep gluteal intramuscular injection. Initiated with two consecutive monthly loading doses (Month 1 and Month 2), followed by injections every 2 months (every 8 weeks) .

Oral Lead-in Option : An optional 4-week oral cabotegravir lead-in (30 mg once daily) may be used to assess drug tolerability prior to receiving the depot injection; however, CDC guidelines endorse direct-to-injection initiation without oral lead-in based on trial safety data.

Superior Clinical Efficacy : In randomized trials, long-acting cabotegravir demonstrated superior efficacy over daily oral TDF/FTC, reducing HIV transmission by 66% in cisgender MSM and transgender women (HPTN 083) and by 88% in cisgender women (HPTN 084) . The superior efficacy was primarily attributable to overcoming the adherence challenges inherent to daily oral regimens.

Injection Window and Oral Bridging : Injections must occur within a window of 7 days before to 7 days after the scheduled 2-month injection date. If a patient expects to miss an injection by more than 7 days, daily oral cabotegravir (30 mg daily) or daily oral TDF/FTC must be prescribed as oral bridging therapy starting 2 months after the last injection and continuing until injections are resumed.

Event-Driven ("2-1-1" or "On-Demand") Oral PrEP

The Regimen : Taking 2 tablets of TDF/FTC 2 to 24 hours before anticipated sex , followed by 1 tablet 24 hours after the initial double dose , and 1 tablet 48 hours after the initial double dose (the IPERGAY protocol).

Candidate Restrictions : The CDC and international guidelines endorse 2-1-1 dosing strictly for adult cisgender MSM engaging exclusively in anal intercourse who have infrequent sexual encounters and can anticipate sex at least 2 hours in advance.

STRICT CONTRAINDICATIONS to 2-1-1 Dosing :

Cisgender women and all individuals engaging in receptive vaginal sex (vaginal mucosal drug saturation requires at least 21 days of daily dosing; 2-1-1 yields subtherapeutic vaginal tissue levels).

Transgender men having vaginal intercourse.

Persons who inject drugs (PWID).

Individuals with chronic Hepatitis B infection (intermittent dosing leads to inadequate HBV suppression and severe rebound viremia/hepatic flare).

Patients taking TAF/FTC (Descovy is not studied or approved for 2-1-1 dosing).

Mandatory Pre-PrEP Screening Protocol

Initiating PrEP without rigorous screening can lead to disastrous consequences, most notably the rapid emergence of antiretroviral drug resistance if PrEP is inadvertently initiated in a patient harboring undiagnosed, acute HIV infection.

Required Baseline Laboratory Testing Checklist

HIV Diagnostic Testing (Documentation of Negative Status) :

Must document a negative laboratory-based HIV-1/2 4th-generation antigen/antibody (Ag/Ab) immunoassay within 7 to 14 days prior to starting or refilling PrEP.

Acute Retroviral Syndrome Assessment : Inquire about any viral syndrome (fever, pharyngitis, adenopathy, rash, myalgias) or condomless exposure within the past 14 to 30 days. If acute retroviral syndrome is suspected or if the patient received post-exposure prophylaxis (PEP) within the preceding 30 days, a plasma HIV-1 RNA NAAT (viral load) must be ordered concurrently, as the viral RNA test has the shortest window period (detectable within 10 to 12 days).

Exam Rule : Never initiate PrEP based solely on an oral fluid rapid test or if an HIV test is pending. If HIV status is indeterminate or positive, withhold PrEP and refer immediately for fully suppressive antiretroviral therapy.

Renal Function (Serum Creatinine and eGFR) :

Required for oral TDF/FTC (must have eGFR >=60 mL/min ) and oral TAF/FTC (must have eGFR >=30 mL/min ). Baseline urinalysis to check for proteinuria/glucosuria is recommended.

Hepatitis B Virus (HBV) Serology (HBsAg, anti-HBs, anti-HBc) :

Both TDF and TAF, as well as emtricitabine, are highly active against Hepatitis B virus polymerase.

The Hep B Flare Warning : If a patient with chronic Hepatitis B (HBsAg-positive) starts TDF/FTC or TAF/FTC, their HBV replication is suppressed. However, if the patient subsequently discontinues PrEP abruptly (e.g., due to loss of insurance, side effects, or changes in sexual activity), severe, life-threatening acute hepatitis exacerbations (flares) and fulminant hepatic failure can occur due to sudden HBV rebound. In HBsAg-positive patients, PrEP should be co-managed with a hepatologist, and if PrEP is discontinued, continuation of alternate anti-HBV therapy (such as entecavir) or intensive clinical hepatic monitoring is mandatory.

If the patient is seronegative (HBsAg, anti-HBs, and anti-HBc all negative), administer the complete Hepatitis B vaccine series.

Baseline Sexually Transmitted Infection (STI) Screening :

Perform multi-site Nucleic Acid Amplification Testing (NAAT) for Chlamydia trachomatis and Neisseria gonorrhoeae (pharyngeal swab, rectal swab, and first-catch urine / vaginal swab) regardless of symptoms.

Serologic screening for Treponema pallidum (syphilis) using non-treponemal or treponemal assays.

Lipid Panel :

Required prior to initiating TAF/FTC due to potential elevations in total cholesterol, LDL, and triglycerides.

Pregnancy Testing :

Urine human chorionic gonadotropin (hCG) in individuals of childbearing potential. TDF/FTC is preferred and established as safe during pregnancy and lactation.

Longitudinal On-PrEP Monitoring Schedule

PrEP requires ongoing clinical surveillance to ensure continued HIV negativity, monitor renal safety, and treat asymptomatic STIs promptly:

Every 3 Months (All Patients on PrEP)

HIV-1/2 4th-generation Ag/Ab immunoassay : Repeat testing is mandatory prior to issuing a 90-day medication refill.

HIV-1 RNA NAAT : Recommended by CDC for all patients on long-acting cabotegravir at every 2-month injection visit. Cabotegravir can delay antibody production during breakthrough infections; RNA testing detects early virologic breakthrough and prevents the selection of INSTI-resistant viral strains.

Symptom Review : Screen for symptoms of acute retroviral syndrome or medication side effects.

Adherence & Behavioral Risk Counseling : Evaluate adherence, pill counts, missed doses, and discuss harm reduction.

Pregnancy Testing : Repeat urine hCG for individuals with childbearing potential.

Every 6 Months

Multi-Site STI Screening : Repeat chlamydia and gonorrhea NAAT at all anatomical sites of sexual exposure (pharyngeal, rectal, urogenital), plus serologic testing for syphilis, regardless of symptoms.

Renal Function (eGFR) : Repeat serum creatinine/eGFR for individuals taking oral TDF/FTC who are aged >=50 years or whose baseline eGFR was <90 mL/min .

Every 12 Months

Renal Function (eGFR) : For all other patients taking oral TDF/FTC or TAF/FTC (e.g., age <50 with baseline eGFR >=90 mL/min).

Fasting Lipid Profile : For patients taking TAF/FTC.

Comprehensive Clinical Reassessment : Evaluate whether PrEP remains indicated based on the patient's ongoing sexual and substance use behaviors.

Post-Exposure Prophylaxis (PEP): Occupational & Non-Occupational (nPEP)

Post-Exposure Prophylaxis (PEP) is an emergency antiretroviral regimen administered to prevent HIV infection following an isolated, high-risk exposure to blood or body fluids (e.g., accidental needlestick, broken condom during sex with an HIV-positive partner, sexual assault, sharing injection equipment).

The Critical 72-Hour Window

Initiation Timeline : PEP must be started as soon as possible following exposure— ideally within 2 hours , and no later than 72 hours (3 days) post-exposure.

Biological Basis : Animal models prove that HIV takes approximately 48 to 72 hours to replicate within dendritic cells and travel to regional lymph nodes. Once systemic lymphatic dissemination occurs, antiretroviral prophylaxis fails. If a patient presents >72 hours after exposure, PEP is not effective and not recommended ; the patient should instead undergo baseline testing and close clinical monitoring.

Duration of Therapy : PEP must be taken consistently for exactly 28 days .

Recommended PEP Regimens (CDC Guidelines)

For adults and adolescents with normal renal function (eGFR >=60 mL/min), the preferred regimen consists of a 3-drug combination incorporating a dual-NRTI backbone plus a high-barrier integrase strand transfer inhibitor (INSTI):

Dual-NRTI Backbone :

Tenofovir disoproxil fumarate (TDF) 300 mg / Emtricitabine (FTC) 200 mg (Truvada) PO once daily. (If eGFR is 30 to 59 mL/min: adjust TDF/FTC dosing interval or substitute Tenofovir alafenamide / emtricitabine [Descovy] PO once daily).

PLUS an Integrase Strand Transfer Inhibitor (INSTI) :

Dolutegravir (Tivicay) 50 mg PO once daily , OR

Raltegravir (Isentress) 400 mg PO twice daily (or Raltegravir HD 1200 mg PO once daily).

Alternative Approved Regimen :

Bictegravir 50 mg / Emtricitabine 200 mg / Tenofovir alafenamide 25 mg (Biktarvy) PO once daily as a single-tablet 3-drug regimen.

Laboratory Testing Cascade for PEP

Baseline Testing (Day 0) : HIV-1/2 4th-generation Ag/Ab test, Hepatitis B serologies (HBsAg, anti-HBs, anti-HBc), Hepatitis C antibody, baseline serum creatinine/eGFR, urine pregnancy test, and baseline STI screening (chlamydia, gonorrhea, syphilis). Crucial : Do not delay the first dose of PEP while waiting for baseline laboratory results.

Follow-up Testing : Repeat HIV Ag/Ab immunoassay at 4 to 6 weeks post-exposure (immediately upon completing the 28-day regimen) and at 12 weeks post-exposure.

Transitioning from PEP to PrEP : If a patient completing a 28-day course of PEP has ongoing, persistent sexual or injection drug behaviors that confer high risk for HIV, they should be transitioned immediately to PrEP without any gap in medication coverage , provided their 4th-generation HIV test at day 28 is confirmed negative.

Loading diagram... Clinical Decision Algorithm for HIV Pre-Exposure Prophylaxis (PrEP) & Post-Exposure Prophylaxis (PEP)