EXECUTIVE SUMMARY

The U.S. Preventive Services Task Force (USPSTF) has issued final recommendations that providers screen for HIV in everyone ages 15-65 years and all pregnant women, as well as younger adolescents and older adults at increased risk for HIV.

  • Pre-exposure prophylaxis (PrEP) also should be offered to people at high risk of HIV, according to USPSTF.
  • Risk factors include male-to-male sexual contact, injection drug use, anal intercourse without a condom, performing vaginal intercourse without a condom and with more than one partner whose HIV status is unknown, exchanging sex for drugs or money, having other sexually transmitted infections or a sex partner with an STI, and a having sex partner who is living with HIV or is in a high-risk category.

The U.S. Preventive Services Task Force (USPSTF) has issued final recommendations that providers screen for HIV in everyone ages 15-65 years, and all pregnant women as well as younger adolescents and older adults at increased risk for HIV.1-3 Pre-exposure prophylaxis (PrEP) also should be offered to people at high risk of HIV, USPSTF recommends.4,5

“Clinicians can make a real difference toward reducing the burden of HIV in the United States,” Douglas Owens, MD, MS, USPSTF chair and Henry J. Kaiser, Jr. professor of medicine at Stanford University, said in a statement. “HIV screening and HIV prevention work to reduce new HIV infections and ultimately save lives.” (View the statement online at: https://bit.ly/2GqUCC7.)

Since 2006, the CDC has recommended universal HIV screening at least once for people ages 13-64 years, with annual or more frequent rescreenings for persons at increased risk. However, new data indicate that such recommendations have not been fully implemented.6

The report authors examined 2016-2017 data from a national population-based survey. Findings indicated that less than 40% of people have undergone an HIV test. Less than 30% of at-risk people were tested in the past year.6

Thirty-five percent of people recommended for HIV testing in 50 jurisdictions where more than half of HIV diagnoses occur received testing in the past year, the report states. In rural areas that are particularly affected by HIV, 26% of people recommended for annual HIV testing were tested in the past year.6

While all teens and adults ages 15-65 years should be screened for HIV, there are a number of risk factors, according to the USPSTF guidance:

• The majority of new HIV diagnoses are attributed to male-to-male sexual contact.7

• Injection drug use also is linked to HIV infection; the prevalence of infection among those who inject drugs is estimated at 1.9%.8

• According to 2017 statistics, males ages 13 years and older represented 81% of new HIV diagnoses.9 While the majority of these new diagnoses were attributed to male-to-male sexual contact, about 10% were attributed to heterosexual contact, 4% to injection drug use, and 4% to both male-to-male sexual contact and injection drug use.9

• In adolescent females ages 13 and above, 87% of all new diagnoses were attributed to heterosexual contact, and 12% to injection drug use.9

Other risk factors include anal intercourse without a condom, performing vaginal intercourse without a condom and with more than one partner whose HIV status is unknown, exchanging sex for drugs or money, diagnosis of other sexually transmitted infections (STIs) or a sex partner with an STI, and a sex partner who is living with HIV or is in a high-risk category.1

PrEP consists of the anti-HIV drugs emtricitabine and tenofovir disoproxil fumarate (Truvada). In its analysis of current evidence, USPSTF found that PrEP is highly effective at preventing HIV, if taken daily.5 PrEP is not for everyone, USPSTF advises; it is for people who do not have HIV, but are at high risk of infection.

Which Patients Are PrEP Candidates?

Patients who have a sex partner who is living with HIV, have sex without a condom with a partner whose HIV status is unknown and who is at high risk for HIV, or share injection drug equipment are definite PrEP candidates.

“Clinicians have the opportunity to protect patients at high risk for HIV by offering PrEP,” Seth Landefeld, MD, USPSTF member and chairman of the department of medicine and the Spencer chair in medical science leadership at the University of Alabama at Birmingham School of Medicine, said in a statement.

“To know which patients are good candidates for PrEP, clinicians need to ask all patients about their sexual history and injection drug use in an open and nonjudgmental way.”

When PrEP is offered, clinicians should provide support to patients to help them follow the daily regimen for maximum protection. (View the statement online at: https://bit.ly/2GqUCC7. Check out the CDC’s Act Against AIDS clinician resources at: https://bit.ly/2AmNJiB.)

The USPSTF recommendations come at a pivotal time, as a national plan has just been proposed to end the HIV epidemic. The U.S. Department of Health and Human Services is seeking funding for the “Ending the HIV Epidemic: A Plan for America” initiative to end the epidemic in the United States within 10 years. The plan, if funded, will focus first on the geographic areas with the greatest HIV burden.

Strategies to End the Epidemic

The plan includes the following four strategies:

  • Early diagnosis of HIV;
  • Rapid and effective treatment to achieve sustained viral suppression;
  • Prevention approaches as PrEP for at-risk populations;
  • Rapid response to HIV clusters to stop new infections.

“Getting tested for HIV is quicker and easier than ever before — and when you take the test, you take control,” according to a press statement from Eugene McCray, MD, director of CDC’s Division of HIV/AIDS Prevention. “It’s my hope that through the initiative to end the HIV epidemic, we will increase testing and early diagnosis, speed linkages to care, and help ensure rapid treatment is available to help save lives and prevent new HIV infections.” (View the statement at: https://bit.ly/2NswPrh.)

REFERENCES

  1. US Preventive Services Task Force, Owens DK, Davidson KW, Krist AH, et al. Screening for HIV infection: US Preventive Services Task Force recommendation statement. JAMA 2019;doi:10.1001/jama.2019.6587.
  2. Chou R, Dana T, Grusing S, et al. Screening for HIV infection in asymptomatic, nonpregnant adolescents and adults: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA 2019;doi:10.1001/jama.2019.2592.
  3. Selph SS, Bougatsos C, Dana T, et al. Screening for HIV infection in pregnant women: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA 2019;doi:10.1001/jama.2019.2593.
  4. US Preventive Services Task Force, Owens DK, Davidson KW, Krist AH, et al. Preexposure prophylaxis for the prevention of HIV infection: US Preventive Services Task Force recommendation statement. JAMA 2019;321:2203-2213.
  5. Chou R, Evans C, Hoverman A, et al. Preexposure prophylaxis for the prevention of HIV infection: Evidence report and systematic review for the US Preventive Services Task Force. JAMA 2019;321:2214-2230.
  6. Pitasi MA, Delaney KP, Brooks JT, et al. HIV testing in 50 local jurisdictions accounting for the majority of new HIV diagnoses and seven states with disproportionate occurrence of HIV in rural areas, 2016-2017. MMWR Morb Mortal Wkly Rep 2019;68:561-567.
  7. Singh S, Song R, Johnson AS, et al. HIV incidence, prevalence, and undiagnosed infections in U.S. men who have sex with men. Ann Intern Med 2018;168:685-694.
  8. Dailey AF, Hoots BE, Hall HI, et al. Vital signs: Human immunodeficiency virus testing and diagnosis delays — United States. MMWR Morb Mortal Wkly Rep 2017;66:1300-1306.
  9. Centers for Disease Control and Prevention. HIV Surveillance Report 2017;29:20.