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Experts Support Use of PrEP Despite New HIV Infection Reported in Adherent PrEP User

A second case of HIV transmission to a person who was adherent to Pre-Exposure Prophylaxis (PrEP) protocols was announced at the HIV Research for Prevention conference. A previous case was reported in February. In both cases, testing revealed that the strain of HIV acquired was resistant to Truvada, the FDA’s only approved drug for PrEP. Despite these two widely reported cases, this mutation is rare and Truvada continues to be highly effective at preventing HIV infection. 

HIV infection while PrEP adherent is most likely to occur due to exposure of an HIV strain resistant to tenofovir or emtricitabine, the component drugs in Truvada. This drug resistance occurs most often when a person living with HIV is not consistent with their treatment protocol. HIV has the highest mutation rate of any biological substance ever recorded, meaning that it rapidly transforms its structure, defenses, and identity. Missing doses of antiretroviral therapy (ART) allows the virus to replicate in presence of ART, increasing the likelihood the it will adapt and develop resistance. With this new resistance, the virus could replicate unchecked, becoming amplified and dominant. Individuals adherent to Truvada may not be protected if they are exposed to a strain of HIV that is already resistant to tenofovir or emtricitabine. Experts have tried to be clear that PrEP is not 100% effective as shown by these two cases. For this reason, the Centers for Disease Control and Prevention (CDC) recommends that PrEP be combined with the use of condoms. At the same time, most experts acknowledge that these cases are extremely rare and continue to support the use of PrEP in populations at risk for HIV infection.

AIDS United’s position statement on PrEP supports nationwide implementation of CDC guidelines on PrEP as an effective prevention strategy for men and women at risk for HIV. We continue to follow the research regarding PrEP including new cases of HIV transmission, despite PrEP adherence. However, it is important not to overreact to these cases as well. Since 2012, more than 79,000 people have taken Truvada as a PrEP in the United States, and yet there have only been just two cases of HIV transmission among those adherent. PrEP remains a highly effective method of HIV prevention. 

As PrEP continues to be implemented in the U.S., another lesson is that the field must continue to combat drug resistance. One way to address drug resistance is to support treatment adherence among people with HIV. Similarly we should provide tools to people who are taking PrEP so that they can adhere to their regimen as well. 

We also should note that these cases reinforce the need for regular (quarterly) STI screenings including for HIV for people who take PrEP. Early discovery of any new HIV infection leads to faster treatment with the benefits of a longer, healthier life as well as reducing the likelihood of future transmission through viral suppression. Finally, we hope that HIV providers and educators will continue to help people to understand the benefits and value of PrEP so that individuals can make informed decisions about deciding to take PrEP. 

Posted By: AIDS United, Policy Department - Friday, November 04, 2016

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