U.S. Preventive Services Task Force recommends PrEP for HIV in high-risk patients

The U.S. Preventive Services Task Force (USPSTF) recommends offering preexposure prophylaxis (PrEP) with effective antiretroviral therapy to patients at high risk for HIV infection.

The Grade A recommendation was based on a systematic review of the literature that looked at the benefits of PrEP with oral tenofovir disoproxil fumarate monotherapy or combined tenofovir disoproxil and emtricitabine. The Task Force also reviewed literature on whether such benefits vary by risk, population, or regimen or dosing strategy, as well as on the diagnostic accuracy of tools to identify high-risk patients, adherence to PrEP in primary care, the association between adherence and effectiveness, and the harms of PrEP for HIV prevention. The recommendation statement and systematic review were published June 11 by JAMA.

The Task Force found convincing evidence that PrEP has substantial benefit for decreasing HIV risk in high-risk patients and that adherence is strongly associated with efficacy. Adequate evidence indicated that PrEP is associated with small harms, such as gastrointestinal and renal adverse effects, the statement said. Based on the review, the Task Force concluded with high certainty that PrEP with oral tenofovir disoproxil fumarate-based therapy has substantial benefit in reducing HIV acquisition in patients who are at high risk.

The Task Force considered patients to be at high risk if they were sexually active men who had sex with men and had a serodiscordant sex partner, inconsistently used condoms, or had syphilis, gonorrhea, or chlamydia in the past six months; if they were heterosexually active women and men who had a serodiscordant sex partner, inconsistently used condoms with a high-risk sex partner who had unknown HIV status, or had syphilis or gonorrhea within the past six months; or if they injected drugs and shared drug-injection equipment or were at risk for sexual acquisition of HIV.

“It is important to note that men who have sex with men and heterosexually active persons are not considered to be at high risk if they are in a mutually monogamous relationship with a partner who has recently tested negative for HIV,” the statement said. “In addition, all persons being considered for PrEP must have a recently documented negative HIV test result.”

The USPSTF noted that it can be challenging to identify high-risk patients due to stigma and discrimination or lack of a trusting relationship between patient and clinician. “It is important that clinicians routinely take a sexual and injection drug use history for all their patients in an open and nonjudgmental manner,” the Task Force said. “If a person is identified as potentially belonging to a high-risk group, then further discussion can identify behaviors that may make that person an appropriate candidate for PrEP.”

Also in JAMA on June 11, the USPSTF updated its 2013 statement on HIV screening, continuing to support it in adolescents and adults ages 15 to 65 years and in those who are outside that age range but are at increased risk for infection. The Task Force also continues to recommend screening in all pregnant women, including those presenting in labor or at delivery with unknown HIV status. Both are Grade A recommendations.