Agreement Form

As part of helping uninfected individuals understand the commitment in taking emtricitabine/tenofovir disoproxil fumarate for HIV-1 PrEP, the Agreement Form for Initiating Emtricitabine/Tenofovir Disoproxil Fumarate for HIV-1 Pre-exposure Prophylaxis (PrEP) has been created. It's important that you use the form to review the factors that may help to identify uninfected individuals at risk. These include:

  • Has partner(s) known to be HIV-1 infected, or
  • Engages in sexual activity within a high prevalence area or social network and has additional risk factors for HIV-1 acquisition, such as:
    • Inconsistent or no condom use
    • Diagnosis of sexually transmitted infections
    • Exchange of sex for commodities (such as money, shelter, food, or drugs)
    • Use of illicit drugs, alcohol dependence
    • Incarceration
    • Partner(s) of unknown HIV-1 status with any of the factors listed above

After you review the risks and benefits with the individual, you must both sign and date the form and file in the individual's medical record. This will help to reinforce the importance of understanding the risks involved with emtricitabine/tenofovir disoproxil fumarate for HIV-1 PrEP. Download a printable version of the Agreement Form.

The information on this site is intended for audiences
of the United States.

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