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Pre-Exposure Prophylaxis (PrEP) Recommended for those at High Risk of HIV Infection

July 23, 2019

HIV Infection PrEP Pill

The United States Preventive Services Task Force (USPSTF) has released revised recommendations for HIV negative adults and adolescents at significant risk of acquiring infection because of certain behaviors to be prescribed pre-exposure prophylaxis (PrEP) with a combination anti-retroviral. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis#consider

Combined tenofovir disoproxil fumarate and emtricitabine is the only PrEP regimen currently approved by the US FDA; it is available in a single tablet taken once a day as Truvada. It is possible that other regimens including generics may be approved in the near future.

The USPSTF recommends that the following persons be considered for PrEP:

Men who have sex with men, are sexually active, and have one of the following characteristics:

A serodiscordant sex partner (ie, in a sexual relationship with a partner living with HIV)
Inconsistent use of condoms during receptive or insertive anal sex
A sexually transmitted infection (STI) with syphilis, gonorrhea, or chlamydia within the past 6 months

Heterosexually active women and men who have one of the following characteristics:

A serodiscordant sex partner (ie, in a sexual relationship with a partner living with HIV)
Inconsistent use of condoms during sex with a partner whose HIV status is unknown and who is at high risk (eg, a person who injects drugs or a man who has sex with men and women)
An STI with syphilis or gonorrhea within the past 6 months

Persons who inject drugs and have one of the following characteristics:

Shared use of drug injection equipment
Risk of sexual acquisition of HIV (see above)

Persons who engage in transactional sex, such as sex for money, drugs, or housing, including commercial sex workers or persons trafficked for sex work, constitute another group at high risk of HIV acquisition and should be considered for PrEP based on the criteria outlined above. Men who have sex with men and women are at risk of HIV acquisition and should be evaluated for PrEP according to the criteria outlined above for men who have sex with men and heterosexually active men.

This approach is fundamentally different than the USPSTF recommendation for HIV screening in which age (15-65) and diagnosis (pregnancy) can be determined without asking questions which many patients will find sensitive because the behaviors are stigmatized and may have legal consequences if disclosed. It is vital that patients be assured that we will hold their information in strict confidence, that it is necessary to help them lower their risk of AIDS.

Taking a sexual history is key to identifying almost all those who would benefit from PrEP. A good brief summary on taking sexual history in primary care was published by Nusbaum and Hamilton in 2002. https://www.aafp.org/afp/2002/1101/p1705.html CDC has online resources for clinicians on PrEP with emphasis on primary care practice.

In addition to PrEP, USPSTF recommends behavioral counseling regarding prevention of HIV infection. In particular, condom use reduces HIV acquisition by 80% and also prevents transmission of other sexually transmitted infections. Communities which have instituted measures such as concerted efforts to refer for substance abuse treatment, needle exchanges, housing for the homeless, have reported reductions in HIV transmission, so be sure your primary care practice has information for referral of patients at risk. CDC has extensive public education material on HIV risk reduction https://www.cdc.gov/hiv/ and specifically on PrEP at https://www.cdc.gov/hiv/guidelines/preventing.html.