Is Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide) for post-exposure prophylaxis (PEP) efficacious in treating gonorrhea in a patient with urethral discharge diagnosed by nucleic acid amplification test (NAAT) urine GC testing?

Biktarvy Is Not Effective for Gonorrhea Treatment in a Patient with Confirmed Infection

Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide) is not effective for treating gonorrhea and should not be used for this purpose, even when prescribed as HIV post-exposure prophylaxis (PEP). While Biktarvy is effective for HIV PEP, a patient with confirmed gonorrhea requires specific antibiotic therapy according to current guidelines.

Gonorrhea Treatment Recommendations

The CDC recommends the following treatment for uncomplicated gonorrhea:

• First-line treatment: Ceftriaxone 250 mg intramuscularly as a single dose PLUS either:
  • Azithromycin 1 g orally as a single dose, OR
  • Doxycycline 100 mg orally twice daily for 7 days 1

This combination therapy approach is essential because:

1. It ensures treatment of potential co-infections (e.g., chlamydia)
2. It helps prevent the development of antimicrobial resistance
3. It increases treatment efficacy for gonorrhea

Why Biktarvy Is Not Appropriate for Gonorrhea

Biktarvy contains antiretroviral medications designed specifically to treat or prevent HIV infection:

• Bictegravir (integrase strand transfer inhibitor)
• Emtricitabine (nucleoside reverse transcriptase inhibitor)
• Tenofovir alafenamide (nucleotide reverse transcriptase inhibitor)

None of these components have activity against Neisseria gonorrhoeae. While Biktarvy has shown good safety, tolerability, and efficacy for HIV PEP 2, 3, it has no antimicrobial effect against gonorrhea.

Management of the Patient with Confirmed Gonorrhea

For a patient who has been diagnosed with gonorrhea by NAAT urine testing:

1. Treat with appropriate antibiotics: Ceftriaxone 250 mg IM plus either azithromycin or doxycycline as recommended above 1

2. Continue HIV PEP if indicated: If the patient requires HIV PEP, Biktarvy can be continued for the full 28-day course alongside appropriate gonorrhea treatment 2

3. Test for other STIs: Ensure comprehensive testing for other potential co-infections including chlamydia, syphilis, and HIV 4

4. Consider extragenital testing: For men who have sex with men, rectal and pharyngeal testing is recommended as urogenital-only testing may miss infections at these sites 4

5. Partner notification: Ensure all sexual partners from the preceding 60 days are evaluated and treated 1

Important Considerations

• Antimicrobial resistance: Gonorrhea has developed resistance to multiple antibiotics over time. Current CDC guidelines reflect the need for combination therapy to combat resistance 1

• Test of cure: Not routinely recommended for uncomplicated gonorrhea treated with recommended regimens, but should be considered if symptoms persist

• Doxycycline PEP: Recent CDC guidelines (2024) discuss doxycycline post-exposure prophylaxis for bacterial STIs, which may be considered for high-risk individuals, but this is separate from HIV PEP 1

• Monitoring for treatment failure: Patients should be advised to return if symptoms persist or recur after treatment

Conclusion

While Biktarvy is an effective and well-tolerated regimen for HIV PEP 2, 3, it has no activity against Neisseria gonorrhoeae. A patient with confirmed gonorrhea requires standard antibiotic therapy according to CDC guidelines, regardless of whether they are also receiving Biktarvy for HIV PEP.