Integrase-Ing Biktarvy: Simplifying Emergency Nonoccupational Postexposure Prophylaxis

Advancements in the treatment and prevention of human immunodeficiency virus (HIV) have significantly evolved over the past decade, driven by the development of novel antiretroviral therapy (ARV) regimens and comprehensive nationwide public health initiatives. A substantial contributor to the declining trend in new HIV infections across the United States can be attributed to the widespread implementation and accessibility of post-exposure prophylaxis (PEP). PEP for non-occupational exposure (nPEP) is a critical preventive intervention that involves the initiation of antiretroviral therapy within 72 hours of potential HIV exposure, administered for a course of 28 days with close monitoring through laboratory testing and clinical follow-up. Despite the proven efficacy of nPEP in preventing HIV transmission, significant barriers to optimal therapy completion persist, directly impacting patient outcomes. Prior to 2025, clinical guidelines recommended a three-drug antiretroviral regimen consisting of tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and either dolutegravir or raltegravir. While clinically effective in preventing HIV seroconversion, this multi-tablet regimen presented numerous challenges that compromised patient adherence and therapy completion rates, including complex dosing schedules requiring multiple daily tablets, increased pill burden leading to decreased adherence, adverse effects particularly associated with TDF, and storage requirements for certain components that created unnecessary drug loss for institutions. These obstacles disproportionately affected vulnerable populations at highest risk for HIV exposure, including individuals experiencing homelessness, those with substance use disorders, and patients with limited healthcare access, ultimately resulting in suboptimal PEP completion rates and preventable HIV infections. Emergency departments serve as critical access points and often represent the first point of healthcare contact for many at-risk patients seeking nPEP, uniquely positioning healthcare providers to intervene during the narrow 72-hour window when nPEP initiation is most effective. In 2025, the Centers for Disease Control and Prevention (CDC) updated clinical guidelines to include bictegravir/emtricitabine/tenofovir alafenamide (Biktarvy) as a first-line option for nPEP. This single-tablet, once-daily regimen offers a favorable side effect profile with reduced renal and gastrointestinal toxicity compared to TDF-based regimens, eliminates storage restrictions that previously posed barriers to adherence, and simplifies dosing to enhance patient compliance throughout the critical 28-day treatment course. Emergency medicine pharmacists are uniquely positioned to address this gap in care and optimize nPEP delivery in the acute care setting through their specialized expertise in recognizing patients who meet criteria for nPEP initiation, conducting rapid medication reconciliation to identify potential drug-drug interactions with antiretroviral therapy, providing critical patient education regarding adherence strategies and the importance of therapy completion, facilitating immediate access to Biktarvy through emergency dispensing or discharge prescription protocols, and coordinating seamless transitions of care to infectious disease specialists or primary care providers for ongoing follow-up. By championing the adoption of Biktarvy as the preferred nPEP regimen in emergency departments, pharmacists can directly contribute to improved therapy completion rates, reduced loss to follow-up, and ultimately decreased incidence of new HIV diagnoses, positioning emergency medicine pharmacists as key stakeholders in institutional and community-based HIV prevention efforts.