New Recommendation Expands Antiretroviral Guidance for HIV

Brian Owens

August 23, 2023

The US Preventive Services Task Force (USPSTF) is expanding its recommendation for antiretrovirals in HIV now that more options are available on the market.

"With these new options we could potentially extend pre-exposure prophylaxis (PrEP) to a wider population," says James Stevermer, MD, a member of the task force and a professor of family and community medicine at the University of Missouri, in Columbia.

The guidance, published August 22 in JAMA, updates the group's previous recommendation from 2019 to take into account the new options that have become available since the US Food and Drug Administration approvals that included a long-acting injectable form.

In the original report, daily oral tenofovir disoproxil fumarate with emtricitabine was the only approved medication available and the taskforce recommended it. Since then, two new regimens have been approved: daily oral tenofovir alafenamide with emtricitabine and the long-acting injectable cabotegravir.

The task force is backing all three options and is recommending that clinicians use whichever formulation is most appropriate for their patients at risk for HIV infection.

Task Force in Primary and Preventative Care

The USPSTF is a volunteer group of experts in primary and preventative care who make recommendations on the best preventative interventions clinicians should take on everything from cancer screening, to preventive aspirin use, to behavioral counseling. The group is convened and supported by the Agency for Healthcare Research and Quality.

Recommendations from this group are particularly helpful for clinicians who may not see HIV as their area of expertise, says Carolyn Chu, MD, chief medical officer of the American Academy of HIV Medicine. "Hopefully, this will catch the eye of people who are not tracking all of the HIV updates," she says.

A person's risk for infection is mostly based on their behavior, Stevermer says. Those who use injectable drugs, particularly if they share needles, those who use condoms inconsistently and do not know their partner's HIV status, and those who have recently had bacterial sexually transmitted infections like gonorrhea and syphilis are all at higher risk.

The efficacy of each of the three options is close enough to equal that it doesn't usually matter which is prescribed, according to the task force. However, daily oral tenofovir alafenamide with emtricitabine is not approved for use by people engaging in receptive vaginal sex. For most people, the best medication option is the one they are most likely able to integrate into their routine. Cabotegravir, for example, which requires injections every 2 months, is an easier method for some people, particularly those who don't think they could successfully take a daily pill.

Reducing Risk

"The evidence is very clear that being able to adhere to taking the medication daily was very closely associated with the effectiveness of PrEP," Stevermer says. "So, everything that we can do to make sure that the person who wants to prevent HIV is getting their PrEP as it is supposed to be taken makes it that much more effective."

Expanding access to antiretrovirals among at-risk groups is an important part of the Ending the HIV Epidemic in the US initiative that aims to reduce new HIV cases by 90% by 2030.

But an editorial published alongside the recommendation in JAMA notes that uptake of PrEP has been disproportionately low among populations most heavily affected by HIV.

In 2021, 78% of White people expected to benefit from PrEP received it, compared with just 11% of Black people and 21% of Hispanic people, despite both of those populations having a higher incidence of HIV than Whites. PrEP use is also substantially lower among cisgender and transgender women, youth, and people who inject drugs.

"We have an intervention that can markedly reduce people's risk of getting HIV and so we want to make sure we get this out to all those populations at increased risk," Stevermer says.

Having multiple options when it comes to PrEP is a big part of expanding access to the treatment for underserved groups, Chu says. "Even though oral tenofovir disoproxil fumarate with emtricitabine has been out for a while, we know it's not getting to everyone, and there may be clinical circumstances that means it's not the right option," she says. "Making sure we are supporting choices so people can make the decision for themselves is important."

But doctors also need to be willing to have an open conversation with their patients and bring up the topic of PrEP in a way that doesn't feel judgemental or stigmatizing, Chu says.

It is also important not to make assumptions about who would want to talk about medication, she adds. "How can we change the narrative around PrEP?" she asks. "The evidence is there, these medications are effective and safe, weave PrEP into your preventive care portfolio to at least start the conversation."

JAMA. Published online August 22, 2023. Full Text, Editorial

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