CMAJ has been made aware of several corrections and clarifications to be made to the Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis, published in the Nov. 27, 2017 issue.1
Corrections
The following corrections have been made at cmaj.ca:
In Appendix 1, on page 14, under heading 2; and on page 9, Box 2, recommendation 2, indications for pre-exposure prophylaxis (PrEP) in heterosexual individuals: The second sentence read, “PrEP may be considered for the HIV-negative partner in heterosexual serodiscordant relationships reporting condomless vaginal or anal sex, where the HIV-positive partner has a low but non-negligible risk of having transmissible HIV [Grade 1B; strong recommendation, moderate quality of evidence).” The recommendation level has been changed to “Grade 2B; weak recommendation, moderate quality of evidence,” as correctly labelled in the guideline (pg. E1450, Box 2).
On page E1455, Box 5, “Special populations” section, “Suspected acute HIV infection” subsection in the guideline; and in Appendix 1, Box 5.1 and Supplementary Table 3: the suggested timing for repeat fourth-generation HIV testing read “7 to 14 days later.” This has been changed to “7 to 21 days later.” The panel of 25 experts who developed the guideline wish to emphasize that the optimal timing for repeat testing must take into consideration the timing of exposure and the window period of the relevant test.
On page E1454, Table 5, final column, final row in the guideline: The list of alternate third drugs for use as nonoccupational postexposure prophylaxis (nPEP) regimens in the published article should have included “Raltegravir HD 1200 mg PO once daily (weak recommendation; very low quality of evidence).” This has been added and conforms with the listing in Appendix 1, pg. 42, Table 5.
In Appendix 1, in Box 2 on pg. 10 and in point 2 on pg. 14; and in the guideline, in Box 2 on pg. E1450, and on pg. E1451, right column, third paragraph: the authors requested that the words “low but” be added, such that the full statement reads “PrEP may be considered for the HIV-negative partner in heterosexual serodiscordant relationships reporting condomless vaginal or anal sex, where the HIV-positive partner has a low but non-negligible risk of having transmissible HIV.”
Clarifications
With respect to definition of undetectable viral load (Appendix 1, pg. 6, second paragraph), the authors wish to make the following clarification: HIV-positive persons with undetectable viral load and no sexually transmitted infections are classified as having negligible or no risk of transmissible HIV. The panel used the definition of less than 40 copies/mL for undetectable viral load because this is the most commonly used definition in clinical care in Canada. However, the panel recognizes that studies on this topic have used different definitions for “undetectable,” most often less than 200 copies/mL.
With respect to Table 4 in the guideline, the authors wish to make the following clarification related to exposures involving compromised skin: Blood or other potentially infectious body fluids that contact compromised skin is classified as a low-risk exposure type. Although Table 4 indicates that nPEP is usually not required for low-risk exposures, the panel wishes to clarify that nPEP may be considered on a case-by-case basis, depending on the likelihood that the source person has transmissible HIV.