Abstract & Commentary
PrEP for HIV
By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University, Editor of Infectious Disease Alert
SOURCE: US Public Health Service. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States — 2014. A Clinical Practice Guideline. http://www.cdc.gov/hiv/pdf/PrEPguidelines2014.pdf
SYNOPSIS: The USPHS has provided an extensive document describing their recommendations for chemoprophylaxis of HIV infection in individuals with high levels of ongoing risk.
Daily preexposure prophylaxis (PrEP) with a fixed dose combination of tenofovir 300 mg and emtricitabine (200 mg) provides a level of protection against HIV infection among individuals with substantial risk that is in excess of 90%. As a consequence, it is recommended as one prevention option for the following adults at substantial risk of infection (as defined below):
• Sexually active men who have sex with men (MSM)
• Heterosexually active men and women
• Adult injection drug users (IDU)
In addition, PrEP should be discussed with HIV-negative heterosexually active men and women whose partners are HIV-infected (discordant couples) with attention to issues of contraception and pregnancy.
HIV infection, either acute or chronic, must be excluded immediately before initiation of PrEP by symptom review. Individuals receiving PrEP should be evaluated every 3 months for the presence of HIV infection and renal function should be evaluated every 6 months. They should have access to additional HIV prevention services and encouraged to maintain complete adherence to their regimen.
Indications for PrEP in adult MSM
• Not HIV infected
• Any male sex partner in previous 6 months (if also sex with women see next section)
• Not in a monogamous partnership with a recently tested HIV-negative man
AND >1 of the following:
• Any receptive or insertive anal sex without condoms in past 6 months
• Any sexually transmitted disease in the past 6 months
• In an ongoing sexual relationship with an HIV-infected male partner
Indications for PrEP for heterosexually active adult men and women
• Not HIV infected
• Any sex with opposite sex partners in previous 6 months
• Not in a monogamous partnership with a recently tested HIV-negative partner
AND >1 of the following:
• Is a man who has sex with both women and men (with latter, see above)
• Infrequently uses condoms during sex with >1 partners of unknown HIV status known to be at substantial risk of HIV infection (IDU or bisexual male partner)
• Is in an ongoing sexual relationship with an HIV-infected partner
Indications for PrEP use by adult IDU
• Not HIV infected
• Any injection of drugs not prescribed by a clinician in past 6 months
AND >1 of the following:
• Any sharing of injection or drug preparation equipment in past 6 months
• Been in a methadone, buprenorphine, or suboxone treatment program in past 6 months
• Risk of sexual acquisition as described in above.
In addition to evaluating individuals for the presence of acute or chronic before initiating PrEP, they should undergo serological testing for hepatitis B virus (HBV) and hepatitis C virus infection. Those susceptible to HBV infection should be vaccinated. Separately, the USPHS has provided checklists and patient information to assist in the initiation and management of PrEP.1
Overall, the new guidelines stress the importance of determining individual risk for HIV, PrEP use, adherence to medication, and regular monitoring of health and risk behaviors. One section that has stirred some controversy is the PrEP recommendation for individuals in an ongoing sexual relationship with an HIV-infected partner. This recommendation has raised questions regarding its applicability when the infected partner is fully virologically suppressed, a circumstance in which the risk of transmission has been found to be minimal.2
References
- US Public Health Service. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States 2014. Clinical Provider’s Supplement. http://www.cdc.gov/hiv/pdf/guidelines/PrEPProviderSupplement2014.pdf
- Loutfy MR, et al. Systematic review of HIV transmission between heterosexual serodiscordant couples where the HIV-positive partner is fully suppressed on antiretroviral therapy. PLoS One 2013;8(2):e55747.
