USPSTF Recommends PrEP for People at Risk of HIV Infection

The US Preventive Services Task Force (USPSTF) is recommending pre-exposure prophylaxis (PrEP) using effective antiretroviral therapy (ART) to help individuals decrease their risk of acquiring HIV if they have a higher risk of infection, according to a recommendation statement published in JAMA.¹ This recommendation is consistent with the 2019 recommendation that clinicians offer PrEP with effective antiretroviral therapy to individuals with a high risk of HIV infection.²

There are approximately 1.2 million people in the United States who are living with HIV. In 2020, there were 30,635 new diagnoses in the United States alone. Most diagnoses of HIV in the United States come from adolescent and adult men (80%) and Black persons (42%). The USPSTF recommends that clinicians prescribe effective ART to reduce the risk of HIV infection.

This new recommendation is for individuals who have an elevated risk of acquiring HIV due to sexual activity or injection drug use. The USPSTF is recommending that sexually active adults and adolescents who have had anal or vaginal sex in the previous 6 months and/or a sexual partner living with HIV, a sexually transmitted infection (STI) in the past 6 months, and a history of inconsisten of no condom use, as well as those who inject drugs or have a partner who injects drugs be considered for receiving PrEP.

Individuals with a recently documented negative HIV test result can be considered for PrEP. Testing with both an HIV antigen-antibody assay and an HIV-1 RNA assay are recommended if oral PrEP or postexposure prophylaxis were taken in the previous 3 months.

Identifying individuals who are at an increased risk of HIV is necessary to identify those who would benefit from PrEP. Individuals with acute or chronic HIV should be excluded from taking PrEP, and STI and pregnancy tests should be conducted. Kidney tests, lipid profile testing, and serologic testing for hepatitis B are recommended before starting PrEP that contains tenofovir. Testing for HIV should continue every 2 to 3 months, depending on the formulation of PrEP.

It is unknown how long it takes to achieve protection from initiation of PrEP, the study authors noted. However, as long as the risk of HIV infection persists, the individual can continue using PrEP. In addition, patients may cease or initiate the use of PrEP as the need arises, including changes in risk of HIV infection, personal preference, or adverse effects of the medication. Patients who are resuming PrEP after discontinuing need the same tests as if they were initiating for the first time.

The risk of being infected by a different STI does not decrease with the use of PrEP. Regular screenings for STIs should be done for individuals taking PrEP. Adherence support is also important, as low adherence to PrEP is associated with a decrease in its effectiveness. Support in this area includes open communication between clinicians and patients, patient education, attention to medication adverse effects, and reminder systems.

Barriers, such as lack of health insurance and belief that an individual is not a candidate for PrEP, can hinder the uptake of PrEP for prevention of HIV. Racial and ethnic barriers also exist, as studies have found that those who use PrEP are primarily White individuals (60.5%) vs Black individuals (7.9%) and Hispanic/Latino individuals (13.8%), even though estimated 40% of people in the United States who qualify for PrEP are Black individuals. The full benefit of PrEP can only be achieved if these barriers and disparities are addressed.

References

1. US Preventive Services Task Force. Preexposure prophylaxis to prevent acquisition of HIV: US Preventive Services Task Force recommendation statement. JAMA. 2023;330(8):736-745. doi:10.1001/jama.2023.14461

2. Final recommendation statement: prevention of human Immunodeficiency virus (HIV) infection: preexposure prophylaxis. US Preventive Services Task Force. June 11, 2019. Accessed August 21, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis