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Key Clinical Updates in Primary Prevention
For men who have sex with men and have creatinine clearance less than 60 mL/min but greater than 30 mL/min, or osteoporosis/osteopenia (or at risk for these conditions), clinicians may opt to use TAF/FTC or injectable cabotegravir PrEP. Oral lead-in dosing of cabotegravir prior to injection should be considered optional, as breakthrough seroconversions occurred during the oral lead-in period in one of the cabotegravir studies, and injectable cabotegravir is well tolerated. When using injectable cabotegravir, the most sensitive HIV testing available should be used. After discontinuation and with ongoing risk of HIV, the cabotegravir tail should be covered with TDF/FTC or TAF/FTC, with quarterly HIV RNA testing performed.
Landovitz RJ et al; HPTN 083 Study Team. N Engl J Med. [PMID: 34379922]
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A. Primary Prevention
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Until a safe and effective HIV vaccine is available, prevention of HIV infection will depend on HIV testing and counseling, including precautions regarding sexual practices and injection drug use, initiation of ART among people with HIV as a prevention tool for transmission to others, pre-exposure and postexposure use of antiretrovirals, perinatal management including antiretroviral treatment of the mother, screening of blood products, and infection control practices in the health care setting.
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1. HIV testing and counseling
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Primary care clinicians should routinely obtain a sexual history and provide risk factor assessment of their patients. Because approximately 13% of people with HIV in the United States do not know they have infection, the USPSTF recommends that clinicians screen for HIV infection in adolescents and adults ages 15 to 65 years at least once in a lifetime. Younger adolescents and older adults who are at increased risk should also be screened, with repeat screening as often as indicated for anyone at ongoing risk. Clinicians should review the risk factors for HIV infection with the patient and discuss HIV prevention strategies and safer needle use as well as the meaning of a positive test. Although the CDC recommends “opt-out” testing in medical settings, some states require specific written consent. For people whose test results are positive, it is critically important that they be connected to medical care. Most public health guidelines and HIV specialists advocate for initiating care and treatment the same day that someone tests positive, including patients in safety-net settings (see C. Antiviral Treatment, below). Referrals for partner-notification services, social services, mental health services, and HIV prevention services should also be provided.
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For patients whose test results are negative, clinicians should review HIV prevention strategies, needle use practices, or both. Pre-exposure prophylaxis (PrEP) and postexposure prophylaxis are highly effective HIV prevention strategies and are reviewed below. To prevent sexual transmission of HIV, only latex or polyurethane condoms should be used, along with a water-soluble lubricant. Although nonoxynol-9, a spermicide, kills HIV, it is contraindicated because in some patients it may cause genital ulcers that could facilitate ...