Acute HIV infection
ICD-10 B23.0; B23.1 · ICD-11 1C62.0

Treatment of Acute HIV Infection in a Patient Who Has Taken Tenofovir-Based Oral PrEP

Clinical Scenario

A new HIV diagnosis is made in a patient who has been taking tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) or tenofovir alafenamide/emtricitabine (TAF/FTC) as oral pre-exposure prophylaxis (PrEP) since their last negative HIV test result.

Prior use of tenofovir-based PrEP raises the possibility that HIV drug resistance mutations may have emerged, which could reduce the efficacy of a standard initial antiretroviral regimen. Regimen selection in this scenario must account for that risk.

Treatment Approach

Consultation with an experienced HIV care provider is recommended. The initial regimen is structured around an integrase strand transfer inhibitor (INSTI) with a high barrier to resistance, combined with two nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs).

Specific regimen options, substitution rules, and the role of baseline genotypic testing are detailed in the full protocol.

Treatment Goals
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References

  1. There is a greater possibility that HIV drug resistance mutations may emerge and reduce the efficacy of an initial ART regimen in patients with a new reactive HIV screening test or a new HIV diagnosis who have taken tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) or tenofovir alafenamide fumarate/emtricitabine (TAF/FTC) as PrEP since their last negative HIV test result.
  2. For such patients, the initial regimen should consist of an integrase strand transfer inhibitor (INSTI) with a high barrier to resistance (e.g., DTG or bictegravir [BIC] or boosted DRV) and 2 nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs).
  3. The initial regimen may be simplified once results of baseline genotypic testing have been reviewed.
  4. The clinicians should implement treatment to suppress the patient's plasma HIV RNA to below detectable levels.
  5. Clinicians should obtain a viral load test 4 weeks after ART initiation to assess the response to therapy.
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