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USPSTF 2019 recommends offering PrEP to patients at high risk of HIV acquisition (A recommendation)
Clinical Question
Should primary care clinicians offer preexposure prophylaxis with antiretroviral therapy to persons at high risk of HIV acquisition?
Bottom line
In this initial 2019 review, the U.S. Preventive Services Task Force (USPSTF) recommends that clinicians offer preexposure prophylaxis (PrEP) with effective antiretroviral therapy to patients at high risk of HIV acquisition (A recommendation). Persons at high risk of HIV infection include men who have sex with men, and heterosexually active women and men who have at least one of the following characteristics: having a sex partner with known HIV, inconsistently using condoms during sex with a high-risk partner whose HIV status is unknown, or having sexually transmitted syphilis or gonorrhea within the past 6 months. Other high-risk individuals include persons who inject drugs and share drug injection equipment, and persons engaging in sex for money, drugs, or housing, including commercial sex workers or persons trafficked for sex work. Transgender women and men should be considered for PrEP on the basis of the same criteria. It is important to know a person is HIV-negative prior to starting PrEP, and routine HIV surveillance is recommended during therapy. 2c
Reference
Study design: Practice guideline
Funding: Government
Setting: Population-based
Synopsis
The USPSTF found 29 studies that evaluated evidence on the benefits and harms of PrEP, instruments for predicting HIV infection, and PrEP adherence. No adequate evidence was found for risk assessment tools that can accurately identify persons at high risk of HIV acquisition. PrEP is associated with a significantly decreased risk of HIV infection versus placebo or no PrEP. Adherence to PrEP is highly correlated with its efficacy in preventing HIV infection. The task force found evidence that PrEP is associated with an increased risk of renal and gastrointestinal adverse events, but serious events are rare; therefore, overall, there is little to no risk of harm from PrEP. No clinical trials of PrEP enrolled pregnant women, and women who became pregnant were withdrawn from participation. It is not known if PrEP is beneficial when a seropositive partner has an undetectable viral load. The Centers for Disease Control and Prevention and the World Health Organization recommend PrEP with tenofovir disoproxil fumarate plus emtricitabine.
Reviewer
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC