USPSTF Issues Recommendation Statements on PrEP, Screening for HIV

The United States Preventive Services Task Force (USPSTF) has issued a new guideline on the use of pre-exposure prophylaxis (PrEP) for HIV prevention¹ and updated its 2013 recommendation on screening people at risk for HIV.²

Similar to its draft recommendation released in November, the task force is recommending that clinicians offer PrEP with effective antiretroviral therapy (ART) for those at risk for infection, which includes men who have sex with men, those at risk through heterosexual contact, and people who inject drugs.

“The USPSTF found convincing evidence that PrEP is of substantial benefit for decreasing the risk of HIV infection in persons at high risk of HIV infection, either via sexual acquisition or through injection drug use,” wrote the task force in JAMA. “The USPSTF also found convincing evidence that adherence to PrEP is highly correlated with its efficacy in preventing the acquisition of HIV infection.”

The recommendation is based on a review of 14 randomized clinical trials, 8 observational studies, and 7 studies of diagnostic accuracy, which demonstrated that PrEP was associated with decreased risk of infection after 4 months to 4 years.³

While the once-daily combination of tenofovir disoproxil fumarate and emtricitabine, sold as Truvada, is the only FDA-approved formulation of PrEP, several studies assessed by USPSTF found that tenofovir disoproxil fumarate alone was effective as PrEP. CDC guidelines note that, given these data, the antiviral drug can be considered as an alternative regimen for high-risk heterosexually active men and women who inject drugs.

In the updated recommendation statement on screening for HIV infection, USPSTF is recommending that clinicians screen adolescents and adults aged 15 to 65 years for HIV infection and that clinicians also screen younger adolescents and older adults who are at an increased risk of infection. The grade A recommendations also include screening for all pregnant women, including those in labor or whose HIV status is unknown.

To update the 2013 recommendation, USPSTF commissioned a systematic evidence review of the benefits and harms or screening for infection in nonpregnant adolescents and adults, as well as the benefits and harms of screening for infection in pregnant women.⁴

“The USPSTF found insufficient evidence to determine appropriate or optimal time intervals or strategies for repeat HIV screening,” the task force noted in a commissioned evidence report,⁵ adding that research is needed on the yield of repeat versus one-time screening for HIV and different repeat screening intervals. However, it wrote that screening is reasonable for those known to be at increased risk of infection.

“The substantial benefit of screening is realized only if detection of HIV is followed by initiation of appropriate ART and provisions of other services for persons found to have HIV,” wrote the taskforce. “Thus, entry into care for persons identified as having HIV is essential.”

In an accompanying editorial⁶ to the recommendation statements, Hyman Scott, MD, MPH, clinical research medical director at Bridge HIV in the San Francisco Department of Public Health, and an assistant clinical professor of Medicine at the University of California, San Francisco (UCSF); and Paul A. Volberding, MD, co-director and principal investigator of the UCSF-Gladstone Center for AIDS Research, professor of Medicine at UCSF, and the director of the UCSF AIDS Research Institute, write that the guidelines represent a maturation of evidence and policy in HIV medicine and a growing consensus regarding application.

“Together, the health gains in HIV treatment, the resulting reduction in transmission, and PrEP provide the necessary tools to end the HIV epidemic,” Scott and Volberding wrote. “Success in the next chapter in confronting this epidemic demands that these tools be widely accessible and used. The USPSTF recommendation statements should help make this happen.”

References:

1. USPSTF. Preexposure prophylaxis for the prevention of HIV infection: US Preventive Services Task Force recommendation statement [published online June 11, 2019]. JAMA. doi:10.1001/jama.2019.6390.

2. USPSTF. Screening for HIV Infection: US Preventive Services Task Force recommendation statement [published online June 11, 2019]. JAMA. doi:10.1001/jama.2019.6587.

3. USPSTF. Preexposure prophylaxis for the prevention of HIV infection: evidence report and systematic review for the US Preventive Services Task Force [published online June 11, 2019]. JAMA. doi:10.1001/jama.2019.2591.

4. USPSTF. Screening for HIV infection in pregnant women: updated evidence report and systematic review for the US Preventive Services Task Force [published online June 11, 2019]. JAMA. doi:10.1001/jama.2019.2593.

5. USPSTF. Screening for HIV infection in asymptomatic, nonpregnant adolescents and adults: updated evidence report and systematic review for the US Preventive Services Task Force [published online June 11, 2019]. doi:10.1001/jama.2019.2592.

6. Scott H, Volberding P. HIV screening and preexposure prophylaxis guidelines following the evidence [published online June 11, 2019]. JAMA.