HIV and PrEP — the Australian general-practice approach

HIV in the Australian general-practice context

Australia has made remarkable progress in the HIV response since the introduction of combination antiretroviral therapy in the 1990s and the PBS listing of PrEP in 2018. Approximately 700 new HIV diagnoses occur each year — down substantially from the peak, reflecting the impact of PrEP, expanded testing, and effective treatment suppression. Approximately 30,000 Australians are living with HIV. Men who have sex with men remain the group most affected (~70% of diagnoses), but heterosexual transmission, people who inject drugs, and communities with recent migration from high-prevalence countries are important populations in Australian general practice.

ASHM HIV Management Guidelines and ASHM PrEP Guidelines are the Australian primary-tier references. The GP’s role spans four domains: testing (normalising and expanding HIV testing), prevention (PrEP prescribing, PEP referral), shared care for stable patients on antiretroviral therapy, and comorbidity management including cardiovascular disease, mental health, bone health, and STIs.

A. Core clinical — the AU general-practice framework

HIV testing — who and when

ASHM recommends that GPs offer HIV testing as part of a comprehensive sexual health screen, opportunistically with any STI presentation, and on request. The standard test is a 4th-generation HIV antigen/antibody combination assay (MBS item 69384 range), which detects both HIV-1/HIV-2 antibodies and p24 antigen with a window period of approximately 2–4 weeks from exposure. A point-of-care rapid test and over-the-counter self-testing kits have expanded access outside clinic settings. HIV RNA or antigen testing is needed if acute seroconversion is clinically suspected (symptoms within 2–4 weeks of high-risk exposure) — the window period for RNA is approximately 7–14 days.

Annual HIV testing is recommended for sexually active MSM and people at ongoing high risk. More frequent testing (every 3 months) applies for those on PrEP. Normalising HIV testing in general practice — framing it as a routine screening component alongside blood pressure and cholesterol — reduces stigma and improves diagnosis rates.

Acute HIV seroconversion — a must-not-miss diagnosis

Acute HIV infection presents 2–4 weeks after exposure with a mononucleosis-like illness: fever, generalised lymphadenopathy, pharyngitis, rash (typically erythematous maculopapular, truncal), myalgia, arthralgia, and headache. The viral load is very high at this stage, making early diagnosis critically important for both clinical care and transmission reduction. A 4th-generation assay is often reactive but may need HIV RNA confirmation. Any patient with this presentation and a plausible exposure history should be referred urgently to an HIV or infectious diseases clinic. PEP is not appropriate once acute infection is confirmed — ART initiation is the priority.

PrEP — pre-exposure prophylaxis

Who is eligible: ASHM PrEP Guidelines define high-risk criteria for PBS-subsidised PrEP:

• MSM or transgender women with condomless anal sex with casual partners
• People with an HIV-positive partner whose viral load is not suppressed (noting that U=U removes transmission risk when suppressed)
• People who inject drugs and share needles or equipment
• Sex workers with condomless sex
• Anyone with a recent bacterial STI (gonorrhoea, syphilis, rectal chlamydia) — indicating a level of sexual risk consistent with PrEP benefit

Standard regimen: emtricitabine 200 mg / tenofovir disoproxil fumarate 300 mg (generic Truvada), one tablet daily. Takes approximately 7 days to reach protective levels in rectal tissue and approximately 21 days in vaginal tissue. On-demand (2:1:1) schedule for MSM: two tablets 2–24 hours before sex, one tablet 24 hours after the double dose, one tablet 48 hours after the double dose. Not recommended for people with hepatitis B co-infection due to the risk of hepatitis B flare on cessation.

PBS access: Authority Streamlined since 2018; any GP can prescribe without a specialist letter. Document clinical indication and confirm HIV-negative status and adequate renal function before prescribing.

Baseline workup before starting PrEP: HIV Ag/Ab (must be negative), renal function (eGFR — tenofovir DF is nephrotoxic at higher doses; switch to tenofovir alafenamide [TAF] formulation if eGFR <60), hepatitis B surface antigen and antibody, full STI screen (syphilis serology, pharyngeal/rectal/urethral swabs for gonorrhoea and chlamydia), hepatitis C antibody.

Monitoring on PrEP: every 3 months — HIV test (mandatory before each prescription), renal function, and full STI screen. Annual hepatitis C in higher-risk groups.

Long-acting injectable PrEP (cabotegravir LAI): HPTN 083 and 084 trials demonstrated superiority to daily oral PrEP. TGA-approved; PBS access is evolving as of 2026 — appropriate for specialist referral in the interim.

PEP — post-exposure prophylaxis

PEP must be initiated within 72 hours of a significant HIV exposure (earlier is substantially better; within 2 hours is optimal). A 28-day course of antiretroviral therapy — typically tenofovir/emtricitabine (as for PrEP) plus dolutegravir or raltegravir — suppresses viral replication and prevents establishment of systemic infection.

Access pathways:

• Emergency departments (preferred for after-hours access)
• Sexual health clinics
• NSW PEPline 1800 PEP NOW (1800 737 669) — 24-hour guidance and access
• State-based PEP access varies; refer early rather than delay

Follow-up: HIV test at 6 weeks and 3 months post-exposure to confirm seroconversion has not occurred. Assess risk factors and discuss transition to PrEP if ongoing high-risk behaviour is present.

HIV management — the GP shared-care role

HIV should be initiated and managed by a specialist HIV clinic. All Australian states have dedicated HIV services through hospital outpatient departments and community sexual health clinics. Once a patient is established on ART with a suppressed viral load and stable CD4 count, GP shared care under ASHM HIV Management Guidelines is appropriate for:

• Prescribing ART (requires Section 100 HIV prescriber accreditation — a brief online application through ASHM)
• 3–6 monthly monitoring: CD4 count, viral load, renal function, liver function, lipids, fasting glucose
• Comprehensive vaccination
• Comorbidity management: cardiovascular risk, bone density (DXA per criteria), neurocognitive screening, cervical screening
• Mental health care (MHCP items 2715/2717, 10 subsidised sessions)
• STI screening every 3 months for sexually active patients
• Medication review for drug interactions

Current single-tablet regimens per Therapeutic Guidelines and AMH: Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide), Triumeq (abacavir/lamivudine/dolutegravir — requires HLA-B*5701 testing before use), Dovato (dolutegravir/lamivudine), and others. All are Section 100 Authority.

B. Evidence appraisal — the landmark findings

Question	Evidence	Quality	Practice implication
ART at any CD4 count	START and TEMPRANO trials — survival benefit; also prevents transmission	🟢	Initiate immediately at diagnosis
U=U — undetectable = untransmittable	PARTNER 2016 (JAMA), PARTNER2, Opposites Attract — zero linked transmissions at undetectable VL	🟢	Counsel routinely; transforms disclosure conversations
Daily oral PrEP (emtricitabine/TDF)	iPrEx, PROUD, IPERGAY — >99% efficacy with adherence	🟢	PBS-subsidised; GP-prescribable
On-demand PrEP for MSM	IPERGAY — non-inferior to daily in high-sexual-activity periods	🟢	Offer as alternative for MSM with episodic sex
Long-acting injectable cabotegravir PrEP	HPTN 083/084 — superior to daily oral PrEP	🟢	Specialist; PBS access evolving
PEP within 72 hours	Multiple observational studies — substantial risk reduction; earlier = better	🟢	Maximum 72 hours; aim for within 2 hours
HIV testing normalisation	Population-level data — expanded testing reduces time to diagnosis and late diagnoses	🟢	Opportunistic offer in general practice
Live vaccines with CD4 ≥200	ASHM/ATAGI guidance — acceptable	🟢	Avoid if CD4 <200 (MMR, varicella, BCG, yellow fever, Zostavax)
Doxycycline PEP for STIs (DoxyPEP)	DoxyPEP trial — reduces chlamydia and syphilis	🟡	Emerging; specialist guidance; antimicrobial stewardship considerations

C. HIV and comorbidities — the expanded GP role

People living with HIV on effective ART have near-normal life expectancy but experience accelerated age-related comorbidities — cardiovascular disease, osteoporosis, neurocognitive impairment, and renal disease — at rates higher than the general population. This is driven by a combination of chronic low-level immune activation, legacy effects of older ART agents, and higher rates of smoking, substance use, and delayed healthcare engagement.

Cardiovascular disease — the Heart Health Check (MBS item 699) is particularly valuable; smoking cessation is the most important modifiable risk. Statin prescribing requires checking for ART drug interactions — some ART agents significantly raise statin levels.

Mental health — depression and anxiety affect approximately 30–50% of people with HIV, driven by stigma, disclosure stress, side effects, grief, and social disadvantage. MHCP referral (items 2715/2717) and peer support through ACON, Thorne Harbour Health, and Living Positive Victoria are integral to care.

Bone health — older ART agents (tenofovir DF, protease inhibitors) reduced bone density; newer TAF-based regimens have a better bone profile. DXA scanning per ASHM HIV Management Guidelines criteria.

Drug interactions — ART has numerous clinically significant interactions: rifampicin (dramatically reduces integrase inhibitor and NNRTI levels), statins (some dramatically increased by protease inhibitors), methadone (some ART lowers methadone levels), combined oral contraceptives (reduced efficacy with some ART), anticonvulsants, and azole antifungals. A pharmacist review of the medication list at every change is essential.

D. Australian operations

MBS items for HIV care

Item	Use
23, 36, 44	Standard consultations
69384 range	HIV 4th-generation Ag/Ab test — bulk-billed
965/967	GP Chronic Disease Management Plan / review — chronic HIV qualifies
2715/2717	Mental Health Care Plan / review
699	Heart Health Check
705	75+ Annual Health Assessment
715	ATSI Health Assessment
10997	Practice nurse services — education, vaccinations, monitoring

PBS

• PrEP (emtricitabine/TDF) — Authority Streamlined; GP-prescribable; confirm HIV-negative + adequate renal function.
• ART (Biktarvy, Triumeq, Dovato, Genvoya, Symtuza, others) — Section 100 Authority; requires HIV s100 prescriber accreditation; bulk-billed at dispensing.
• Long-acting injectable cabotegravir — TGA-approved; PBS criteria evolving.
• Hepatitis B treatment (tenofovir, entecavir) — Authority Required; tenofovir DF or TAF cover both HIV and hepatitis B in coinfection.
• PEP — accessed through emergency/sexual health services; subsidised.

Notifiable disease and partner notification

HIV is a notifiable disease in all Australian states and territories. Diagnoses must be reported to state public health (typically via the treating pathology laboratory, but the diagnosing doctor carries responsibility). Offer partner notification support — either patient-led disclosure with GP counselling, or health department-facilitated contact tracing. Document that U=U counselling and partner notification discussion occurred.

Key Australian HIV organisations

• ASHM — Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine — clinical guidelines and practitioner education
• ACON — NSW community HIV and sexual health support
• Thorne Harbour Health — Victorian community HIV services
• Living Positive Victoria — peer support
• HealthDirect HIV information — consumer-facing
• Better Health Channel — HIV

E. Special populations

Pregnancy and HIV. ART throughout pregnancy, initiated as early as possible. Specialist obstetric and HIV co-management is essential. Vertical transmission is negligible when viral load is undetectable at delivery. Vaginal delivery is appropriate when viral load is suppressed; Caesarean section is recommended if viral load remains detectable at term. Formula feeding is recommended in Australia given the ready availability of safe alternatives — this differs from recommendations in low-resource settings. Pre-conception counselling for women with HIV on ART should include a review of teratogenicity data for specific ART agents.

ATSI Australians. HIV rates among Aboriginal and Torres Strait Islander Australians are disproportionately higher in some remote regions, particularly in the context of higher STI rates and social determinants of health. The ATSI Health Assessment (MBS 715) provides an annual structured opportunity for testing and prevention conversations. A culturally safe, non-judgemental approach and connection with ATSI health workers is fundamental.

People who inject drugs. Needle and syringe programs (NSPs) — available free through public health departments and many community pharmacies — reduce HIV and hepatitis C transmission substantially. PrEP is effective in this population when adherence is feasible. Hepatitis C coinfection should be screened at every encounter; direct-acting antivirals are highly effective and GP-prescribable.

Older adults. An increasing proportion of people with HIV in Australia are aged over 55, reflecting both long-term survivors and late diagnoses. Polypharmacy interactions between ART and medications for hypertension, dyslipidaemia, osteoporosis, and diabetes require careful review. Frailty assessment and comprehensive geriatric principles apply.

When to escalate

Refer or transfer urgently for:

• Suspected acute HIV seroconversion — same-day HIV clinic or emergency referral
• Opportunistic infection (Pneumocystis pneumonia, CMV retinitis, oesophageal candidiasis, cryptococcal meningitis, Kaposi sarcoma) — hospital admission
• CD4 <200 with systemic features — urgent specialist review
• PEP access within 72 hours of exposure — ED or sexual health clinic
• Sexual assault — dedicated sexual assault service plus immediate PEP and forensic documentation
• Pregnancy with HIV — specialist obstetric/HIV co-management from first trimester
• Mental health crisis — Lifeline 13 11 14, Beyond Blue 1300 22 4636

Routine specialist referral for:

• Newly diagnosed HIV — for ART initiation and workup
• Complex ART interactions or resistance
• Hepatitis B or C coinfection requiring specialist input
• HIV-associated neurocognitive disorder

What this article is and is not

This is general health information based on Australian clinical guidelines — ASHM HIV Management Guidelines, ASHM PrEP Guidelines, Therapeutic Guidelines, AMH, and the Department of Health’s National HIV Strategy — alongside key clinical trial evidence including the PARTNER trials. It is not personal medical advice and does not create a doctor–patient relationship. HIV testing, PrEP prescribing, ART management, and monitoring decisions are made with your own GP or HIV specialist based on your individual circumstances.

For support and information: ACON, Thorne Harbour Health, Living Positive Victoria, HealthDirect — HIV, ASHM.

For PEP access after high-risk exposure: NSW PEPline 1800 PEP NOW (1800 737 669) or your nearest emergency department — do not wait.

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Sources cited

1. ASHM HIV Management Guidelines
2. ASHM PrEP Guidelines
3. Therapeutic Guidelines (eTG) — Infectious diseases
4. Australian Medicines Handbook
5. Department of Health — Eighth National HIV Strategy
6. Rodger AJ et al. — PARTNER study: U=U (JAMA 2016)
7. HPTN 083/084 — Long-acting injectable cabotegravir PrEP
8. ACON — NSW HIV and sexual health support
9. Thorne Harbour Health
10. Living Positive Victoria
11. HealthDirect — HIV, PrEP and PEP
12. Better Health Channel — HIV