Ask an expert: HIV in primary care

Dear Editor,

I read with interest the excellent article by Singh and Ivens, and would highlight several other aspects relevant to primary care clinicians caring for people living with HIV.

Many people living with HIV, such as gay, bisexual and other men who have sex with men with multiple partners, are at higher risk of mpox infection and therefore are recommended mpox vaccination according to Green Book recommendations (https://assets.publishing.service.gov.uk/media/67699d2d4e2d5e9c0bde9d4b/...)

For patients with a history of PrEP exposure and suspected recent HIV acquisition, atypical presentations may be observed such as HIV indeterminate serology and an undetectable or low RNA viral load. Discussion with a local expert, or with a national clinical service for people with unusual HIV test results, is recommended (imperial.idris@nhs.net) in this circumstance (https://bhiva.org/wp-content/uploads/2024/10/HIV-testing-guidelines-2020...).

Although it's true that HIV-2 infections are observed mainly in people with links to West Africa, HIV-1 is likely still more common than HIV-2 in many countries in that region, although data on HIV-2 prevalence are generally more limited (Sci Rep. 2020 Jul 22;10:12174. doi: 10.1038/s41598-020-68806-5 ; Clin Infect Dis. 2011 Mar 15;52(6):780–787. doi: 10.1093/cid/ciq248)

Regarding antiretroviral therapy, indinavir although an example of the the protease inhibitor class, has been avoided for more than a decade due to its significant toxicity, with boosted darunavir being the preferred agent of the class. Efavirenz, although a well-known non-nucleoside reverse transcriptase inhibitor, is often now avoided for patients naïve to therapy due to CNS toxicity, with doravirine being a preferred NNRTI agent currently.

Dual oral therapy is also increasingly common such as one nucleoside reverse transciptase inhibitor (eg lamivudine) plus an integrase inhibitor (egs dolutegravir).

Injectable therapies are also increasingly available, consisting of an integrase inhibitor (cabotegravir) paired with a non-nucleoside reverse transcriptase inhibitor (rilpivirine) administered every 2 months.

Kind regards,
Dan Bradshaw