USPSTF finalizes recommendation on HIV PrEP

Key takeaways:

• The recommendation is consistent with the task force’s 2022 draft and 2019 final recommendations.
• Risk factors for HIV include sharing injection needles, having a recent STI and having sex without condoms.

Clinicians should prescribe pre-exposure prophylaxis to individuals at high risk for HIV to prevent infection with the virus, the U.S. Preventive Services Task Force declared in a final recommendation statement.

The A-grade recommendation is consistent with the task force’s draft recommendation released last December and its 2019 ruling on pre-exposure prophylaxis (PrEP) use in high-risk individuals.

“PrEP is an essential tool to help reduce rates of HIV in our nation,” USPSTF Member John B. Wong, MD, said in a press release. “To prevent HIV, it’s important that health care professionals prescribe PrEP to patients at increased risk and discuss which form of this medication would be best for them.”

Previous research has shown that many primary care physicians do not screen patients for HIV PrEP eligibility. The CDC reported that there were 36,136 new HIV diagnoses in the United States in 2021, with 67% coming from male-to-male sexual contact. The Northeast had the highest rate of diagnosed people with HIV among all regions, with 411.4 per 100,000 people.

According to the USPSTF, PrEP should be used only in individuals at increased risk, so clinicians should discuss patients’ sexual histories and drug injection activities in an open and shared approach.

Factors that can increase the risk for HIV include having sex with someone who has HIV, having a recent sexually transmitted infection, sharing injection needles and not using condoms consistently, particularly with individuals who have an increased risk, the task force noted.

PrEP medications approved by the FDA include Truvada (emtricitabine/tenofovir disoproxil fumarate; Gilead Sciences) and Descovey (emtricitabine/tenofovir alafenamide; Gilead Sciences), both of which are oral medications, and Apretude (cabotegravir; ViiV Healthcare), the first approved long-acting injectable PrEP.

In a final evidence report, Roger Chou, MD, a professor of medicine at the Oregon Health & Science University, and colleagues found 11 randomized clinical trials that reported oral PrEP was associated with a decreased risk for HIV infection compared with placebo or no PrEP (RR = 0.46; 95% CI, 0.33-0.66), and higher adherence to PrEP resulted in greater efficacy. Additionally, cabotegravir demonstrated a decreased risk for HIV in cisgender men who have sex with men (RR = 0.33; 95% CI, 0.18-0.62) and cisgender women (RR = 0.11; 95% CI, 0.04-0.31) compared with emtricitabine/tenofovir disoproxil fumarate and emtricitabine/tenofovir alafenamide.

HIV continues to disproportionally affect certain populations. In 2021, 8,883 Black men received an HIV diagnosis from male-to-male sexual contact compared with 5,726 white men, the CDC reported.

“We’re still seeing that many people who could benefit from PrEP aren’t receiving this highly effective medication, particularly in Black, Hispanic and Latino communities,” USPSTF Member James Stevermer, MD, MSPH, said in the release. “It’s critical for health care professionals to keep these disparities in mind and to have conversations with patients who are at risk about proven ways to prevent HIV, including taking PrEP.”

In a related editorial, Albert Y. Liu, MD, MPH, director of HIV prevention interventions at the San Franisco Department of Public Health, and colleagues wrote that the USPSTF recommendation highlights the need to support efforts promoting PrEP adherence.

“The CDC guidelines point to several approaches to support medication adherence, including establishing trust and bidirectional, nonjudgmental communication; providing simple explanations regarding medication dosing and managing adverse effects; and tailoring oral PrEP dosing to a patient’s daily routine and using reminder devices,” they wrote.

The researchers also underlined the need for “novel approaches” to address current barriers in PrEP treatment.

“Clinicians may benefit from public health detailing (educational outreach from health department representatives) on available PrEP options and how to prescribe them and counsel patients and from support tools such as electronic health record algorithms to identify persons at risk for HIV acquisition,” they wrote.

References:

• Chou R, et al. JAMA. 2023;doi:10.1001/jama.2023.9865.
• Liu A, et al. JAMA. 2023;doi:10.1001/jama.2023.11700
• New HIV diagnoses and people with diagnosed HIV in the US and dependent areas by area of residence, 2021. https://www.cdc.gov/hiv/basics/statistics.html. Accessed Aug. 18, 2023.
• Pre-exposure prophylaxis. https://www.hiv.gov/hiv-basics/hiv-prevention/using-hiv-medication-to-reduce-risk/pre-exposure-prophylaxis/. Accessed Aug. 18, 2023.
• Task force issues final recommendation statement on PrEP for HIV prevention. https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/hivprep-bulletin.pdf. Published Aug. 22, 2023. Accessed Aug. 22, 2023.
• USPSTF. JAMA. 2023;doi:10.1001/jama.2023.14461.