Johnson Kelly A, Chen Miao-Jung, Kohn Robert, Sachdev Darpun, Bacon Oliver, Lee Sulggi, Cohen Stephanie E
Department of Medicine, University of California San Francisco, San Francisco, CA; and.
San Francisco Department of Public Health, Population Health Division, San Francisco, CA.
J Acquir Immune Defic Syndr. 2021 Jun 1;87(2):818-825. doi: 10.1097/QAI.0000000000002638.
Initiating pre-exposure or post-exposure prophylaxis (PrEP/PEP) in the setting of undiagnosed acute HIV (AHI) could cause antiretroviral resistance. We sought to characterize clinical outcomes and drug resistance mutations among individuals prescribed PrEP/PEP with undiagnosed AHI at a San Francisco sexually transmitted disease clinic.
In our PrEP/PEP program, patients are tested for HIV using a point-of-care antibody test. If negative, patients are started on prophylaxis and screened for AHI using pooled HIV RNA (5-10 days turn-around). We used 2-drug PEP until 05/2016.
We identified patients who had as-yet-undiagnosed AHI on the day of PrEP/PEP start between 2011 and 2018, then used our clinical record and surveillance data to describe HIV resistance and clinical outcomes.
Of 1758 PrEP and 2242 PEP starts, there were 7 AHI cases among PrEP users (0.40%) and 6 among PEP users (0.30%). Median times for linkage to HIV care, initiation of HIV treatment, and viral suppression were 7, 12, and 43 days. On initiation of HIV care, 3 patients (23%) were found to have an M184 mutation 7-12 days after starting PrEP/PEP. All 3 had genotyping performed on stored serum available from the date of PrEP/PEP start, each of which demonstrated wild-type virus. All 3 patients achieved durable viral suppression.
Although rare (occurring <0.5% of the time), AHI in the setting of PrEP/2-drug PEP can result in an M184 within days. Even with M184, persons with AHI achieve viral suppression when rapidly linked to care and initiated on antiretroviral therapy. Providers should consider AHI screening when starting PrEP/PEP.
在未诊断出急性HIV（AHI）的情况下启动暴露前或暴露后预防（PrEP/PEP）可能会导致抗逆转录病毒耐药性。我们试图描述在旧金山一家性传播疾病诊所中，被开具PrEP/PEP但未诊断出AHI的个体的临床结局和耐药性突变情况。
在我们的PrEP/PEP项目中，使用即时检验抗体检测法对患者进行HIV检测。如果检测结果为阴性，患者开始接受预防治疗，并使用混合HIV RNA（周转时间为5 - 10天）对AHI进行筛查。在2016年5月之前，我们使用两药方案的PEP。
我们确定了在2011年至2018年期间开始PrEP/PEP当天尚未诊断出AHI的患者，然后利用我们的临床记录和监测数据来描述HIV耐药性和临床结局情况。
在1758例开始PrEP治疗和2242例开始PEP治疗的患者中，PrEP使用者中有7例AHI病例（0.40%），PEP使用者中有6例（0.30%）。与HIV治疗机构建立联系、开始HIV治疗以及实现病毒抑制的中位时间分别为7天、12天和43天。在开始接受HIV治疗时，3例患者（23%）在开始PrEP/PEP后**7 - **12天被发现存在M184突变。所有3例患者均对从PrEP/PEP开始之日起保存的血清进行了基因分型，结果均显示为野生型病毒。所有3例患者均实现了持久的病毒抑制。
尽管罕见（发生率<0.5%），但在PrEP/两药方案PEP情况下的AHI可在数天内导致M184突变。即使存在M184突变，AHI患者在迅速与治疗机构建立联系并开始接受抗逆转录病毒治疗后仍可实现病毒抑制。在开始PrEP/PEP时，医疗服务提供者应考虑进行AHI筛查。
