The US Preventive Services Task Force (USPSTF) recommends HIV screening in adults and children, and well as in pregnant women, and now recommends offering preexposure prophylaxis (PrEP) to those at high risk for infection. The updated guidance was published online June 11 in JAMA.
“While the first USPSTF guideline on HIV screening was a modest update of its prior work, the preexposure prophylaxis (PrEP) guideline is new. The Recommendation Statement is extremely timely, given a national initiative to end the HIV epidemic, and the accompanying evidence report shows PrEP to be both safe and highly effective in preventing HIV acquisition,” Hyman Scott, MD, and Paul A. Volberding, MD, write in an accompanying editorial.
The PrEP recommendation also means that private insurers will have to cover the cost of the drugs, according to rules established by the Affordable Care Act.
“Clinicians can make a real difference toward reducing the burden of HIV in the United States,” task force chair Douglas K. Owens, MD, MS, said in a press release. “HIV screening and HIV prevention work to reduce new HIV infections and ultimately save lives.”
The new guidance are all grade A recommendations, meaning there is high certainty of benefit, as described in evidence reviews published June 11 in JAMA alongside the USPSTF recommendation statements.
“In 2013, the USPSTF recommended screening for HIV infection in adolescents and adults aged 15 to 65 years, screening in younger adolescents and older adults at increased risk, and screening in all pregnant women. The current updated recommendation continues to strongly recommend screening for HIV infection in adolescents and adults aged 15 to 65 years, younger adolescents and older adults at increased risk, and all pregnant persons,” the USPSTF statement says.
Task force member John Epling Jr, MD, MSEd, said in a news release, “Screening for HIV is important so that everyone knows their HIV status, and those with HIV can begin treatment right away…Today’s treatments help people live long, healthy lives and lower the risk of passing HIV to others,” continued Epling, professor of family and community medicine at the Virginia Tech Carilion School of Medicine in Roanoke, Virginia.
In addition, antiretroviral therapy reduces the risk for HIV transmission to sex partners who are uninfected. Also, diagnosis and treatment among pregnant women significantly reduces the risk for HIV transmission from mother to infant.
The Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics, the American College of Physicians, and the American Academy of Family Physicians recommend routine screening for HIV infection in all pregnant women using an opt-out approach, and rapid screening for women who present in labor whose HIV status is unknown.
The CDC and ACOG recommend repeat testing during the third trimester in women with risk factors and in women living or receiving care in high-incidence settings who had a negative test result earlier in pregnancy; the CDC notes that repeat testing in the third trimester may be considered for all women with a negative test result early in pregnancy.
While screening and treatment can reduce the risk for transmission, individuals at high risk for infection should be offered PrEP, according to the new guidelines. When taken daily, PrEP is effective at preventing HIV. However, using PrEP less often than instructed can cause it to become less effective.
The task force authors note that there are benefits and potential harms associated with use of PrEP, including kidney problems and nausea, and the harms may outweigh the benefits for some patients.
Clinicians can identify people at high risk for HIV by inquiring about high risk behaviors, such as having sex with someone who is infected with the virus, and by sharing injection needle equipment. In addition to using PrEP to prevent HIV infection, people should use a condom during sex and should use clean needles and syringes when injecting drugs
“[C]linicians should support PrEP expansion. While PrEP uptake has been increasing in the United States, with an estimated 17% of the 1.1 million uninfected people who may benefit having a current prescription by the end of 2018, it is disproportionately lower among women, persons younger than 25 years, and those who live in southern US states and in states without Medicaid expansion,” Diane V. Havlir, MD, and Susan P. Buchbinder, MD, write in an editorial published online today in JAMA Internal Medicine.
In their editorial, Scott and Volberding applaud the task force for the thoughtfulness and power of their new recommendations. “The recommendation for PrEP, adding the full endorsement of the USPSTF, is of great importance and is needed to expand access and use of this effective HIV prevention strategy. While newer developments, including a new formulation of tenofovir or the use of injectable, long-acting drugs, were not included in this Recommendation Statement, these treatment strategies could be included in future iterations if supported by the high-quality evidence demanded by the task force.”
“Clinicians have the opportunity to protect patients at high risk for HIV by offering PrEP,” task force member Seth Landefeld, MD, says. “To know which patients are good candidates for PrEP, clinicians need to ask all patients about their sexual history and injection drug use in an open and nonjudgmental way,” continued Landefeld, chairman of the Department of Medicine and the Spencer Chair in Medical Science Leadership at the University of Alabama at Birmingham School of Medicine.
Clinicians should also provide support to patients taking PrEP to help them follow the daily regimen for maximum protection.
HIV remains a significant public issue, with approximately 40,000 diagnosed cases per year in the United States. HIV infection rates have fallen; however, infection rates among some groups are rising, particularly among young adults.
“Ending HIV as an epidemic in the United States by 2030 will only succeed if individuals and institutions from multiple sectors find ways to implement testing, treatment, and prevention strategies across the nation. This is no small task; success will require addressing complex issues of health inequities, discrimination, and affordable care,” Havlir and Buchbinder write.
Havlir and Buchbinder reported receiving nonfinancial drug donation for NIH-funded research from Gilead Sciences outside the submitted work. Volberding reported serving on a data and safety monitoring board for Merck. The remaining authors have disclosed no other relevant financial relationships.
All members of the Task Force received reimbursement and an honorarium for travel to USPSTF meetings.
JAMA Intern Med. Published online June 11, 2019. Havlir and Buchbinder editorial