USPSTF Recommends Clinicians Prescribe HIV PrEP to All High-Risk Patients

The US Preventive Services Task Force has issued a draft recommendation on HIV screening and prevention, upgrading pre-exposure prophylaxis (PrEP) to Grade A and recommending that clinicians offer the treatment to people at high risk of HIV.

The benefits of PrEP for the prevention of HIV are well-documented; when adhered to consistently, the treatment reduces the risk of acquiring HIV by more than 90%. Most recently, the first study to evaluate population-level roll-out of PrEP among men who have sex with men—a patient population at high risk of contracting HIV—found a rapid decline of new HIV infections in just one year.

“The evidence is clear: when taken as prescribed, PrEP is highly effective at preventing HIV,” Seth Landefeld, MD, a member of the task force, said in a statement. “To make a difference in the lives of people at high risk for HIV, clinicians need to identify patients who would benefit and offer them PrEP.”

The task force identified 12 randomized clinical trials that evaluated the efficacy of PrEP versus placebo or no PrEP, one of which was of fair quality because of an open-label design while the other 11 were of good quality. Trial participants varied, with 6 trials enrolling men and women at an increased risk of HIV through heterosexual contact, 4 trials enrolling men who have sex with men or transgender women, 1 enrolling both men who have sex with men and high-risk women, and 1 enrolling people who inject drugs.

All trials also included behavioral and adherence counseling. One small trial reported no cases of HIV. In the 11 other trials, the rate of HIV ranged from 1.4% to 7% over 4 months to 4 years among those taking placebo or no PrEP and 0% to 5.6% among those taking PrEP. A meta-analysis showed that PrEP was associated with reduced risk of HIV compared to placebo or no PrEP (relative risk, 0.46, 95% CI 0.33-0.66); absolute reduction, —2.0 (95% CI –2.8% to –1.2%) after 4 months to 4 years.

They also found a strong association between level of adherence and effectiveness of the treatment, with higher levels of adherence leading to greater reductions in risk of infection.

The draft recommendation drew applause from the HIV community as accessibility to PrEP has remained one of the biggest challenges in widespread dissemination of the treatment, with just 5 states accounting for nearly 50% of PrEP users.

AIDS United commented on the recommendation saying, “While not yet final, these recommendations bode well for the future accessibility of PrEP and would ensure that insurance plans be required to cover the medication at no cost to anyone designated ‘high risk,’ including gay and bisexual men, people who inject drugs, heterosexual individuals in serodiscordant relationships, or persons with a recent sexually transmitted infection.”

The task force also posted a draft recommendation for clinicians to screen everyone age 15 to 65 and all pregnant women for HIV. Younger adolescents and older adults at increased risk should also be screened, according to the recommendation.