Pyra et al. sought to incorporate some of the additional detail in the CDC PrEP indication guidance that notes clinicians should consider the local epidemiological context. They used a criterion that prescribed PrEP for all persons in zip code areas with 2% or more HIV prevalence. This did not resolve observed PrEP ratio disparities. It is important to note that the authors did not use such prevalence thresholds in at-risk populations. For instance, a 2% or even 10% HIV prevalence threshold assessed for MSM or transwomen populations would result in universal indication for all members of each group, resolving PrEP ratio disparities.
The article by Pyra et al. has several limitations. It is from a single health center that serves sexual and gender minority populations, making generalizability challenging. Yet the poor performance of PrEP indication criteria is consistent with both cohort data and our expectations for indication criteria that consist mainly of risk behavior data. As the authors note, PrEP indications in the data set may be underreported because of data limitations of electronic medical records. Last, as the authors acknowledge, the study used an ecological design with cross-sectional data, a design that does not allow direct exploration of whether lower PrEP indication caused lower PrEP prescribing. Self-referral into PrEP has been found to be common in other studies, and some clinicians may not use PrEP indication criteria. Nonetheless, given that many clinicians report being aware of and using CDC PrEP guidance, it seems likely that it has some impact on shaping PrEP discussions between providers and their patients.
Am J Public Health. 2020;110(3):267-268. © 2020 American Public Health Association