New CDC guidelines for HIV post-exposure prophylaxis

Acquisition of HIV infection following potential exposure may occur occupationally in health care workers or, much more frequently, outside working sites, in persons engaged in high-risk behaviors, either sexual or through injection drug use. The use of antiretroviral drugs either before or soon after HIV exposure may prevent primary viral infection. The US CDC released updated recommendations for non-occupational post-exposure prophylaxis (PEP) in May 2025 (Tanner et al., MMWR 2025; 74: 1-56).

The major news in the CDC guidelines for HIV PEP refers to five aspects. First, encourage taking meds within 24 h, and no later than 3 days post-exposure. Second, favor easier access to users, which may include pre-approved standing medical prescriptions and open 24/7 pharmacy stores. Third, consider as a prioritize source of HIV infection, contacts for whom there are doubts. Fourth, consider integrase inhibitors as part of cornerstone drug regimens. One single pill bictegravir-emtricitabine-tenofovir is the preferred option instead of the older multi-pill and multi-dosing regimens. Alternatively, dolutegravir can be used in combination with tenofovir-lamivudine or emtricitabine. Fifth, for those receiving PEP for 1 month, passing directly through pre-exposure prophylaxis (PrEP) should be considered if HIV risk practices persist.

As stated in a recent editorial (Gulick R. Rev Anti-Infect Ther 2025), the new guidelines represent a significant “rally,” committing all efforts to ensure access and uptake of antiretrovirals among individuals engaged in high-risk HIV practices. This commitment to the universal use of PEP follows the steps already taken to favor the widespread use of PrEP. Briefly, any HIV-negative person who is engaged in high-risk behaviors for HIV acquisition should receive antiretrovirals to prevent viral acquisition. The global PrEP user count experienced substantial growth in 2020, exceeding 900,000 individuals (Traeger et al. Lancet HIV 2023; 10: e690-2). By 2025, more than one million people worldwide are under PrEP.

In light of a compensatory effect noticed for a wide range of sexually transmitted infections with continuous rising following the widespread use of PrEP (Soriano et al. AIDS Rev 2023; 26: 127-135), criticisms have arisen about the free provision of meds to persons who do not modify their risk behaviors.

The risk is falling into “utilitarianism.” Thus, the new PEP recommendations should give proper information and behavioral requests for individuals who remain voluntarily at HIV risk. There is no doubt about the difference existing between victims of sexual assault (i.e., rape) and individuals having sex with multiple partners, rejecting condoms and/or using drugs. Should it not be more reasonable to provide prevention with medications that are given freely, along with behavioral interventions seeking to reduce further risk of HIV infection to others or to oneself? Most would agree that the answer is yes. Otherwise, medical doctors may feel alienated and instrumentalized, becoming “blind prescribers.” This is not personalized medicine, nor patient-centered individual care.

The risk of making huge commitments to enhance access to medications without providing proper information and requesting a reduction in risky behaviors is that governments become complicit, and that doctors renounce providing the best care for their patients. For example, the major benefit for any injection drug user is not ensuring his access to clean drugs but supporting him to abandon the addiction (Soriano and Gallego, Nat Rev Gastroenterol Hepatol 2013; 10: 568-9). A discussion about these caveats should have enriched the updated CDC guidelines.