Pre-exposure Prophylaxis Use History in People With Antiretroviral Resistance at HIV Diagnosis: Findings From New York City HIV Surveillance and Partner Services, 2015–2022

Abstract Background Drug resistance may be acquired in people starting human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) during undiagnosed infection. Population-based estimates of PrEP-related resistance are lacking. Methods We used New York City surveillance and partner services data to measure the effect of PrEP use (tenofovir disoproxil fumarate/tenofivir alafenamide fumarate with emtricitabine) history on the baseline prevalence of M184I/V mutations in people with HIV diagnosed in 2015–2022. PrEP use was categorized as “recent” (defined as PrEP stopped ≤90 days before diagnosis), “past” (PrEP stopped >90 days before diagnosis), or “no known use.” Resistance-associated mutations were determined using the Stanford algorithm. We used log binomial regression to generate the adjusted relative risk (aRR) of M184I/V by PrEP use history in people with or without acute HIV infection (AHI). Results Of 4246 people with newly diagnosed HIV and a genotype obtained within ≤30 days of diagnosis, 560 (13%) had AHI; 136 (3%) reported recent and 124 (35%) past PrEP use; and 98 (2%) harbored M184I/V. In people with AHI, recent PrEP use was associated with a 6 times greater risk of M184I/V than no known use (aRR, 5.86 [95% confidence interval, 2.49–13.77]). Among people without AHI, the risk of M184I/V in recent users was 7 times that in people with no known use (aRR, 7.26 [95% confidence interval, 3.98–13.24]), and in past users, it was 4 times that in those with no known use (4.46 [2.15–9.24]). Conclusions PrEP use was strongly associated with baseline M184I/V in New York City, regardless of AHI status. Ordering a nucleic acid test when indicated after assessment of exposure, antiretroviral history, and AHI symptoms can decrease PrEP initiation in people with undetected infection.