Canadian panel issues HIV PrEP, nPEP guideline

A panel of experts is recommending prophylaxis medications, including particular regimens, for several patient demographics at risk for HIV infection.

The panel with the Canadian Institutes of Health Research (CIHR) published the pre-exposure prophylaxis (PrEP) and nonoccupational post-exposure prophylaxis (nPEP) treatments in the Canadian Medical Association Journal.

“The large financial cost of HIV infection and the young age of those newly diagnosed — most new cases occur in those aged 30 to 39 years — underscore the economic and social importance of preventing new infections,” Darrell H.S. Tan, MD, PhD, an infectious diseases physician and researcher at St. Michael’s Hospital in Toronto, and colleagues wrote.

Tan was among the 25 panel members from throughout Canada who developed the guideline with the Biomedical HIV Prevention Working Group of the CIHR’s Canadian HIV Trials Network. The group’s work included consulting literature on PrEP and nPEP regimens.

Tan and colleagues recommended PrEP for men who have sex with men (MSM) and transgender women who had anal sex without a condom in the previous 6 months and who meet any of several criteria.

Those criteria are the presence of infectious syphilis or a rectal bacterial STD; the use of nPEP more than once; an ongoing sexual relationship with someone who has HIV and a substantial risk for transmitting it; and an MSM HIV risk index greater than 10.

The panel also recommended PrEP for heterosexuals who had condomless vaginal or anal sex with someone who has HIV and a substantial risk for transmitting it.

The group recommended a PrEP regimen of once-daily tenofovir disoproxil fumarate with emtricitabine (TDF/FTC).

It recommended nPEP for patients who present no later than 72 hours after moderate or high-risk exposure with a person who has HIV and a substantial risk of transmitting it.

The panel recommended three potential first-line nPEP regimens. All contain TDF/FTC, combined with either raltegravir, dolutegravir or a combination of darunavir and ritonavir.

The panel listed other circumstances in which PrEP or nPEP can be considered, including PrEP for people who share drug injection paraphernalia with those who have a non-negligible risk for HIV infection.

Citing previous studies, the group noted that, in Canada, the risk for HIV infection among MSM is 131 times higher than that among other men, and that the incidence of HIV infection among people who inject drugs is 59 times higher than that among others.

Targeting high-risk populations can help head off further infections, panel members said.

“We hope that this guideline will contribute to reducing HIV incidence in Canada by improving the quality of care, increasing access to care, reducing inappropriate variation in practice and promoting the rigorous evaluation of biomedical prevention strategies nationwide,” they wrote.

In the United States, TDF/FTC is marketed under the trade name Truvada (Gilead Sciences), raltegravir is marketed under the trade name Isentress (Merck), dolutegravir is marketed under the trade name Tivicay (ViiV Healthcare), darunavir is marketed under the trade name Prezista (Janssen Pharmaceuticals) and ritonavir is marketed under the trade name Norvir (AbbVie). – by Joe Green

Disclosures: Tan reports he has received grants from the CIHR and Ontario HIV Treatment Network during the study. He also reports personal fees from Merck and GlaxoSmithKline, as well as grants and personal fees from Gilead and ViiV Healthcare, outside the study. Please see the study for all other authors’ relevant financial disclosures.