Who Should Be Taking the HIV Prevention Pill Today?

Current PrEP Guidance from the U.S. Public Health Service

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The daily use of the drug Truvada (tenofovir + emtricitabine) has been shown to reduce a person's risk of HIV by as much as 92%. The strategy, known as HIV pre-exposure prophylaxis (PrEP), is regarded as an effective means by which to stop the spread of the HIV to uninfected persons and to potentially reverse infection rates in high-risk populations.  

Currently, of all high-income countries in North America and Europe, the U.S. has both the highest HIV incidence rate (50,000 new infections each year) and the second highest HIV prevalence rate (0.6%, or approximately 1.2 million HIV-infected people) all countries.

 Only Lavtia, a country with less than two million citizens and 10,000 diagnosed infections, has a higher prevalence rate (0.7%).

As result of these statistics, the U.S. Public Health Service (USPHS) released its updated clinical practice guidelines on May 14, 2014, calling for the daily use of PrEP in the HIV-negative individuals at substantial risk of infection, as follows:

Sexually active men who have sex with men (MSM) who are not in a monogamous relationship with a recently tested HIV-negative man, and meet one or more of the following criteria:

Sexually active men who have sex with men and women (MSMW) who are not in a monogamous relationship with a recently tested HIV-negative partner, and meet one or more of the following criteria:

  • Engage in condom-less anal sex (receptive or insertive).
  • Have had a sexually transmitted infection (STI) within the past six months.
  • Are in a serodiscordant (mixed status) relationship with an HIV-positive partner.

Sexually active heterosexual men or women who are not in who are not in a monogamous relationship with a recently tested HIV-negative partner, and meet one or more of the following criteria:

  • Infrequently use condoms with one or more partners of unknown HIV status with substantial risk of HIV (injecting drug users, MSMW).
  • Are in a serodiscordant (mixed status) relationship with an HIV-positive partner.

Injecting drug users (IDUs) who meet have injected drugs in the past six months, and meet one or more of the following criteria:

In addition, PrEP can be prescribed to mixed status (serodiscordant) couples who either want to conceive or who already expecting. Both the FDA labeling and perinatal antiretroviral treatment guidelines provide for this.

What If I'm Not on the List?

Ultimately, the decision to prescribe PrEP must be made on a case-by-case basis, with the aim of assessing a person's individual risk of infection and the means by which to mitigate such risk. If you believe that you qualify for PrEP, it is important to work with a trained counselor or health professional to ensure that you understand the benefits and limitations of treatment.

PrEP should never be considered a substitute for condoms or used in place of full-time combination therapy in an HIV-infected partner.  

PrEP can only be prescribed by a doctor and requires both an HIV test prior to start of therapy and every three months thereafter. Medicaid and most U.S. insurance plans cover the cost of PrEP, while co-pay drug assistance is available for those who qualify through Gilead's Truvada for PrEP Medication Assistance Program.

Sources:

Centers for Disease Control and Prevention (CDC). “Pre-Exposure Prophylaxis (PrEP).” Atlanta, Georgia; accessed November 6, 2014.

World Health Organization (WHO). “Prevalence of HIV among adult 15 to 49 – Data by country.” Geneva, Switzerland; accessed November 6, 2014.

World Bank Group. “Country and Lending Groups.” Washington, D.C.; accessed November 6, 2014.

U.S. Public Health Service (PHS). "Preexposure Prophylaxis for the Prevention of HIV Infection in the United States - 2014: A Clinical Practice Guideline." Washington, D.C.; published May 14, 2014; accessed November 6, 2014.

National Institutes of Health (NIH). "Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States." Bethesda, Maryland; accessed November 6, 2014.

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