New Recommendations Aim to Slow HIV Epidemic

By Will Boggs MD

November 27, 2018

NEW YORK (Reuters Health) - Updated draft recommendations from the U.S. Preventive Services Task Force support universal HIV screening in adolescents and adults, as well as preexposure prophylaxis (PrEP) with effective antiretroviral therapy for individuals at high risk of HIV acquisition.

"It is important that clinicians ask their patients about their sexual history and about use of injection drugs to identify people at risk for HIV," said Dr. Seth Landefeld of the University of Alabama at Birmingham School of Medicine, a member of the task force.

"For patients who may be at risk for HIV, clinicians should ask additional questions to figure out that person's level of risk and discuss PrEP if the person is at high risk. When taken as prescribed, PrEP is very effective at preventing HIV infection," he told Reuters Health by email.

The U.S. Preventive Services Task Force (USPSTF) recommendation statement and evidence review on both screening for HIV infection and PrEP were posted for public comment at on November 20. The public comment period is open through December 26.

In the first draft statement, USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years, as well as younger adolescents and older adults who are at increased risk for infection. Pregnant women should also be screened for HIV infection, including those who present in labor or at delivery whose HIV status is unknown.

These recommendations are based on evidence that identification and early treatment of HIV infection substantially reduce the risk for AIDS-related events or death, decrease the risk for HIV transmission to uninfected sex partners and reduce the rate of mother-to-child transmission.

The group found insufficient evidence to identify optimal time intervals or strategies for repeat HIV screening.

The Centers for Disease Control and Prevention (CDC) recommends annual screening in persons at increased risk, and both the CDC and the American College of Obstetricians and Gynecologists recommend repeat prenatal HIV screening during the third trimester of pregnancy in women with risk factors for HIV acquisition and in women in high-incidence settings.

All sexually active adolescents and all adults at increased risk for sexually transmitted infections could also benefit from intensive behavioral counseling, according to the draft statement.

In the second draft statement, USPSTF recommends that clinicians offer PrEP with effective antiretroviral therapy to persons who are at high risk of HIV acquisition.

Dr. Landefeld highlighted several behaviors and factors that can put people at high risk for HIV, including: Having a sex partner who is HIV positive; having sex without a condom with a partner whose HIV status is unknown and who is at high risk for HIV; recently having a sexually transmitted infection; sharing drug injection needles and syringes; and exchanging sex for money or drugs.

"The fact that many people who would benefit from PrEP are not taking it is a concern," he said. "The CDC estimates that about 1.2 million people are at high risk for HIV and would benefit from PrEP, but there were only about 80,000 people taking PrEP in 2016. The Task Force is calling for more research into ways to increase the use of PrEP. By releasing this recommendation, the Task Force is providing guidance to clinicians on offering PrEP and how to identify patients who would benefit from PrEP."

"PrEP helps prevent HIV, but not other sexually transmitted infections," Dr. Landefeld cautioned. "People who take PrEP should continue to use condoms and practice other behaviors to reduce the risk of contracting another sexually transmitted infection."

Dr. Julia L. Marcus from Harvard Medical School, in Boston, Massachusetts, who has studied PrEP in various settings, told Reuters Health by email, "These draft recommendations would be a huge step in the right direction for HIV prevention in the U.S. PrEP is highly effective but vastly underused, even 6 years after FDA approval, and there are stark racial disparities in uptake."

"Providers are essential to PrEP implementation, but many lack familiarity with PrEP and face challenges in identifying patients at risk of HIV acquisition," said Dr. Marcus, who was not involved in the USPSTF's work.

"These recommendations from the USPSTF would put PrEP on the radar of primary care providers across the U.S., but if we're going to scale up PrEP in primary care, we'll need to develop effective and equitable HIV risk prediction tools to support providers in identifying patients who may benefit from PrEP."

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USPSTF 2018.