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HIV antiretroviral preexposure prophylaxis

Richard Tjan
Submission date: Wednesday, 02 December 2015
Published date: Monday, 14 December 2015
DOI: http://dx.doi.org/10.18051/UnivMed.2013.v32.69-70

Abstract


According to 3 field trials conducted in Africa, one among African women and two among
heterosexual couples, antiretroviral preexposure prophylaxis for prevention of HIV-1 has been
shown to be effective.(1-3) In preexposure prophylaxis, persons without HIV infection are given
an oral drug before they have sexual contact with HIV-infected partners.(4) The drug in question
is tenofovir disoproxil fumarate (TDF), a prodrug of tenofovir.(1) On the basis of the 3 field trials,
the Antiviral Drugs Advisory Committee of the Food and Drug Administration has recommended
a combination of antiretroviral drugs (tenofovir/emtricitabine) for preexposure prophylaxis of
HIV.(5)
TDF is currently indicated for the treatment of HIV in adults over 18 years of age or
hepatitis B virus (HBV) infection in adults, or both. The drug is called a nucleotide reverse
transcriptase inhibitor (NRTI), preventing the synthesis of viral copies by HIV reverse
transcriptase or HBV DNA polymerase.(6) To retard the emergence of TDF resistance, the drug
is usually given in combination with another antiviral, such as emtricitabine (FTC). Nucleic acid
testing for HIV virus when starting preexposure prophylaxis, may reduce the risk of resistance,
but it is at present not an option in developing countries because of its high costs. Rare but
potentially serious adverse reactions to TDF are lactic acidosis and toxic effects on the liver and
kidneys.(6) Because administration of TDF to healthy noninfected persons implies using the drug
for a prolonged period of many years, the long-term safety of TDF and the TDF-FTC combination
has to be clearly established.(4)
There is also a real possibility that preexposure prophylaxis may lead to relaxation of the
customary precautions on the part of the sexual partners, such as engaging in increased risky
sexual behavior or abandoning the use of conventional prophylactic measures (e.g. condoms). (4)
This matter should be a problem for health educators.
From a practical point of view, because of the potential of serious liver and kidney disease
caused by TDF, the medical practitioner should prescribe preexposure prophylaxis only in high
risk cases, and not for prevention of HIV in otherwise healthy individuals, e.g. blood bank
personnel or dental practitioners with a low risk of exposure to HIV, which are currently not
indicated. Prescription should be done on an individual basis.
Indeed, the old Hippocratic advice of not too readily prescribing any new modes of treatment,
or in plain words - Wait and watch- still holds true. This is presumably one of the reasons for not
blindly or overenthusiastically accepting HIV preexposure prophylaxis.

Keywords


HIV; antiretroviral

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References


Van Damme L, Corneli A, Ahmed K, Agot K, Lombaard J, kapiga S, et al. for the FEM-PrEP Study Group. Preexposure prophylaxis for HIV infection among African women. N Engl J Med 2012;367:411-22.

Thigpen MC, Kebaabetswe PM, Paxton LA, Smith DK, Rose CE, Segolodi TM, et al. for the TDF2 Study Group. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med 2012;367:423-34.

Baeten JM, Donnell D, Ndase P, Mugo NR, Campbell JD, Wangisi J, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med 2012;367:399-410.

Cohen MS, Baden LR. Preexposure prophylaxis for HIV - here do we go from here? N Engl J Med 2012;367:459-61.

Mascolini M. FDA panel endorses Truvada for pre-exposure prophylaxis. International AIDS Society, May 12, 2012. Available at: http://www.iasociety.org/Article.aspx? elementId=14505. Accessed 13 August 2013.

World Health Organization. Patient information leaflet. HOPAR part 3 11/2010, version 1.0.


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