Preexposure prophylaxis (PrEP) with tenofovir and emtricitabine (Truvada; Gilead Sciences, Foster City, California, USA) has revolutionized HIV prevention efforts, demonstrating impressive efficacy in those who are highly adherent. However, there remains a risk of developing antiretroviral resistance to the components of PrEP if started in undiagnosed acute infection or with breakthrough infection, which can narrow subsequent antiretroviral therapy options. We describe a case that highlights the consequences of initiating PrEP during the acute seroconversion window period. This report underscores the importance of ensuring HIV seronegativity possibly with HIV RNA prior to PrEP initiation, and of providing proper patient education regarding acute seroconversion symptoms.
A 50-year-old man had a negative fourth-generation HIV assay on 2 December 2016 and was simultaneously prescribed Truvada for PrEP. Almost immediately thereafter, the patient developed a flu-like illness and felt too poorly to initiate PrEP until his illness resolved mid-December. He then initiated and continued Truvada without incident and returned to see his provider on 10 January. Screening for sexually transmitted infections was performed on that day because of observance of a generalized maculopapular rash. HIV-1 antibody was positive. The patient discontinued the Truvada several days later upon learning of his positive HIV test. The patient came to our centre to establish care for his HIV and a genotype was performed showing M184V mutation.
Recently reported prevalence rates of transmitted drug resistance in Washington DC vary between 17% and 22.5%, with the prevalence of the M184V mutation being 2.8% and 4.3% in two reports [1–3]. Although the mutation in this patient could be a result of transmitted drug resistance, it is also possible that it was selected for by his short-term use of Truvada as PrEP during acute seroconversion when the HIV RNA concentration is extremely high. This was particularly impactful for this patient because it eliminated all single-tablet regimen options for him.
The fourth-generation HIV antibody/antigen assays are able to detect HIV infection in most people 2–6 weeks (13–42 days) after infection, whereas nucleic acid amplification can detect HIV infection in most people 1–4 weeks (7–28 days) after infection [4]. It is possible that this patient had detectable HIV RNA at baseline testing prior to provision of PrEP, which may have prevented the unfortunate cascade of events that then transpired. Current clinical practice guidelines from the Centers for Disease Control and Prevention recommend baseline HIV RNA testing only in those patients who have had signs or symptoms of acute HIV infection in the prior 4 weeks [5]. It may be worthwhile considering baseline HIV RNA in all patients presenting for initiation of PrEP. Furthermore, a thorough discussion with patients of signs and symptoms of acute seroconversion is meaningful and may have made this patient think twice before initiating PrEP too late.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
References
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Transmitted HIV drug resistance is high and longstanding in metropolitan Washington, DC.
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