COMMENTARY

HIV Guidelines Updated: Four Groups That Should Receive PrEP

Jonathan Mermin, MD, MPH

Disclosures

May 14, 2014

Editorial Collaboration

Medscape &

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Hello. I'm Dr. Jonathan Mermin, Director of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at CDC. I'm pleased to speak with you today as part of the CDC Expert Video Commentary series on Medscape.

I will provide a brief overview of CDC's newly released guidance on the use of daily oral antiretroviral preexposure prophylaxis (PrEP) for HIV prevention in the United States.[1]

These formal US Public Health Service guidelines follow our interim recommendations[2,3,4] that were released soon after study results[5,6,7,8,9] showed substantial efficacy and safety for the use of a daily, fixed-dose combination of tenofovir and emtricitabine (Truvada®) to prevent HIV. With these guidelines, CDC is recommending consideration of the use of PrEP for the following high-risk groups:

Men who have sex with men (MSM);

Persons at high risk for HIV through heterosexual intercourse;

HIV-negative partners in an HIV-discordant relationship; and

Persons who inject drugs.

Estimates indicate that in the United States, as many as 275,000 uninfected gay and bisexual men and 140,000 uninfected partners in HIV-discordant heterosexual couples could benefit from PrEP.

As clinicians, you have the power to increase awareness and uptake of this new prevention intervention, and to ensure that your patients who are currently uninfected with HIV have a greater chance to remain so. The added protection afforded by PrEP is dependent on both clinicians and patients.

There are 3 critical points in the guidelines I would like to call out for you today.

Adherence is key. PrEP is more effective when taken daily, as prescribed. For example, in a study[5] of MSM and transgender women, the overall reduction in HIV acquisition was 44%; among people who self-reported adherence of 90% or greater, reduction in HIV risk was 73%; and among those whose blood samples indicated adherence, HIV acquisition was reduced by more than 90%.

PrEP should only be prescribed to patients who are truly uninfected with HIV. If PrEP is given to a person with HIV, there is a risk of developing an antiretroviral therapy-resistant virus. This highlights the benefits of testing for HIV with a test that detects antigen -- or viral RNA -- as well as antibodies, before initiating PrEP. You should also ask your patients about any symptoms of a recent or current viral illness that may be a sign of acute HIV infection. Patients should be re-tested every 2-3 months to confirm that they do not have HIV.

Adverse effects are rare. The adverse effects of PrEP are mostly mild nausea and vomiting in the first month. Mild reductions in creatinine clearance have also occurred infrequently.

In closing, you can make a big difference in reducing new HIV infections in the United States in 2 ways:

By assisting those at high risk for HIV to obtain access to prevention information, condoms, drug treatment and PrEP, if indicated; and

By helping those with HIV access antiretroviral therapy and risk-reduction information, and encouraging them to help their partners get tested for HIV.

Thank you for your time today, for listening to our discussion about PrEP, another tool that can alter the course of the HIV epidemic in the United States.

For more information, go to www.cdc.gov/hiv.

Web Resources

CDC PrEP Guidelines

CDC PrEP Guidelines Supplement

Jonathan Mermin, MD, MPH, is Director of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP).

Prior to his appointment, Dr. Mermin served as Director of the Division of HIV/AIDS Prevention, NCHHSTP, from 2009 to 2013. Under his leadership, the Division spearheaded a new approach to HIV prevention, called High Impact Prevention, that aligned funding with epidemiology and ensured that program and research activities had the greatest effect on reducing incidence and improving health equity.

A Captain in the US Public Health Service Commissioned Corps, Dr. Mermin served as Director of CDC-Kenya and Health and Human Services Public Health Attaché for the US Embassy from 2006 to 2009, where he oversaw CDC's largest country office, implementing programs and research involving a broad range of infectious diseases, including HIV, malaria, tuberculosis, and emerging infections. From 1999 to 2006, he was Director of CDC-Uganda where he oversaw CDC's HIV prevention and care programs, including implementation of the first antiretroviral treatment program funded by CDC outside of the United States, and the development of a basic care package that was incorporated into the President's Emergency Plan for AIDS Relief (PEPFAR) and World Health Organization guidelines.

Dr. Mermin began his career at CDC in 1995 as an Epidemic Intelligence Service (EIS) officer with the Foodborne and Diarrheal Diseases Branch. He completed an internal medicine residency at San Francisco General Hospital and a preventive medicine residency at CDC and the California Department of Health Services. He is a graduate of Harvard College and Stanford University School of Medicine, and received his MPH from Emory University. He has co-authored more than 150 scientific articles. He currently serves as Adjunct Professor at Emory University School of Public Health.

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