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  • 1.  Acute HIV while (non)-adherent to PrEP

    Posted 01-11-2022 00:25
    Fellow experts & HIV enthusiasts!
    Within one week, I've come across the use and/or suggestion of a 4-drug regimen for patients exposed to PrEP who seroconvert HIV+

    Last week:
    New pt est care at my office, hx of PrEP exposure (inconsistent use) now HIV+ and was started on 4-drug regimen of Tivicay + Symtuza prior to seeing me.
    Today: I read on National HIV Curriculum; "Some experts, however, would consider utilizing a more aggressive four-drug initial regimen, such as darunavir (boosted with cobicistat or ritonavir) plus dolutegravir plus either tenofovir alafenamide-emtricitabine or tenofovir DF-emtricitabine, until results from the genotypic drug resistance test became available." BUT NO REFERENCE.

    Quick literature search found no reference to this practice. Is this experimental? Accepted practice? Standard of Practice?

    I've read how Biktarvy (biktegravir-FTC-TAF) works well despite M184V resistance (which would be the presumptive mutation in someone exposed to PrEP who then tests positive for HIV), and could potentially still be used (as opposed to 4-drug regimen). 
    What do you folks do?

    Thoughts? (and thanks!)

    Kurtis Mohr, MD, AAHIVS (he/him/his)
    HIV Medicine Fellow, Kaiser Permanente

  • 2.  RE: Acute HIV while (non)-adherent to PrEP

    Posted 01-11-2022 16:57
    This would be a good indication for a pre-treatment genotype. In the absence of K65R I suspect Biktarvy would work.

    Ian Gilson
    Sargeant Internal Medicine Clinic
    Shorewood WI

  • 3.  RE: Acute HIV while (non)-adherent to PrEP

    Posted 01-12-2022 16:58
    Dear Kurtis,
    You raise some important questions regarding initiating ART for PrEP-breakthrough acute HIV infection.
    I agree that finding evidence-based data supporting the 4-drug regimen (DRV/cobi/TAF/FTC + DTG) will be challenging. This falls into the category of "some experts recommend" area.
    There was an excellent review of RAMs detected at PrEP-breakthrough, new HIV infection from a very large African cohort (>100,000 persons on TDF/FTC or TDF/3TC PrEP) presented at IAS 2021 (PowerPoint Presentation ( Interestingly, they found a very low incidence of PrEP failure as well as resistance mutations. Of note, in their African cohort, they found 22% NNRTI (transmitted) RAMs and 23% NRTI RAMS (M184V/I or TDF-related).
    The GS 4030 and BRAAVE studies did demonstrate successful ART switch to BIC/TAF/FTC in patients with pre-existing NRTI mutations (M184V/I and TDF-related) in PWH already suppressed on a DTG-based of many other regimens. From these studies, one can assume that either a 3-drug BIC- or DTG-based regimen work well with some limited pre-existing NRTI RAMs.

    W. David Hardy
    Los Angeles CA