On June 11, the U.S. Preventive Services Task Force (USPSTF) posted final recommendation statements and evidence reports on screening for and preventing HIV infection.
Based on its review of the evidence on nonpregnant adolescents and adults,(www.uspreventiveservicestaskforce.org) as well as pregnant women,(www.uspreventiveservicestaskforce.org) the USPSTF recommended(www.uspreventiveservicestaskforce.org) that clinicians should routinely screen people ages 15-65 for HIV infection; younger adolescents and older adults at increased risk for infection should also be screened. These are both "A" recommendations.(www.uspreventiveservicestaskforce.org)
In addition, the task force recommended that physicians screen all pregnant women for HIV infection, including those who present in labor or at delivery whose HIV status is unknown. This is also an "A" recommendation.
This final recommendation statement is consistent with the USPSTF's 2018 draft and 2013 final recommendation statements.
- On June 11, the U.S. Preventive Services Task Force posted a final recommendation that clinicians should screen all people ages 15-65 for HIV infection; younger adolescents and older adults at increased risk for infection should also be screened.
- The task force also recommended that physicians screen all pregnant women for HIV infection, including those who present in labor or at delivery whose HIV status is unknown.
- In a separate final statement, the USPSTF recommended that clinicians offer pre-exposure prophylaxis with effective antiretroviral therapy to patients at high risk of acquiring HIV.
When that 2013 recommendation was released, the AAFP issued its own recommendation that differed only on the age (18 instead of 15) at which to initiate routine screening for HIV infection.
After the USPSTF posted its 2018 draft recommendation, Jennifer Frost, M.D., then-medical director for the AAFP's Health of the Public and Science Division, told AAFP News the Academy recommends screening in low-risk individuals starting at age 18 instead of 15 because of the low prevalence of infection and low rate of new infection in adolescents, as well as the lack of data on the benefits of screening this age group.
In a separate final recommendation statement,(www.uspreventiveservicestaskforce.org) the USPSTF recommended that clinicians offer pre-exposure prophylaxis with effective antiretroviral therapy to patients at high risk of acquiring HIV; an "A" recommendation.
This final recommendation statement and evidence summary(www.uspreventiveservicestaskforce.org) represent the first time the task force has addressed PrEP use.
Response to Public Comment
Draft versions of these recommendations and evidence summaries were posted for public comment on the USPSTF website from Nov. 20 to Dec. 26, 2018.
In response to commenters on the HIV screening recommendation, the task force added information and clarified language regarding assessment of risk, high-prevalence HIV settings, and patients who may be at increased risk and warrant rescreening, as well as the importance of linking to care after an HIV diagnosis. The USPSTF also clarified that patients not at increased risk may not need rescreening.
Additionally, the task force clarified language describing the epidemiology of HIV and provided more details on the HPTN 052 study(www.hptn.org) from the HIV Prevention Trials Network. The USPSTF also added information about the data it considered in its discussions about the age at which to start and end routine screening.
AMA Delegates Approve New Policy on HIV-related Issues
HIV infection and related issues took center stage during this year's AMA House of Delegates Annual Meeting, with delegates adopting a pair of measures that address various aspects of the disease.
The first of these directs the AMA to strongly advocate for funding plans that focus on
- early diagnosis of the infection;
- treatment to achieve sustained viral suppression;
- preventing at-risk individuals from acquiring the infection, including through the use of preexposure prophylaxis; and
- rapidly detecting and responding to emerging clusters of HIV infection.
The second measure calls for the AMA to
- advocate for repeal of legislation that criminalizes nondisclosure of HIV status by those living with the disease and
- work with other stakeholders to develop a program to destigmatize HIV infection by educating the public, physicians and other health care professionals about advances in HIV treatment that minimize the risk of transmission through viral load suppression and PrEP.
"Screening for HIV is important so that everyone knows their HIV status and those with HIV can begin treatment right away," said family physician and task force member John Epling, M.D., M.S.Ed., in a news release.(www.uspreventiveservicestaskforce.org) "Today's treatments help people live long, healthy lives and lower the risk of passing HIV to others."
In response to comments on the recommendation for PrEP use for HIV prevention, the USPSTF clarified language describing risk groups and high-risk activities in the Clinical Considerations(www.uspreventiveservicestaskforce.org) section.
In the same section, the task force also added information about the high burden of HIV in transgender women and the risk of HIV transmission in patients living with HIV who have a suppressed viral load. In addition, the USPSTF added details on the likelihood that specific activities will lead to the transmission of HIV and on the prevalence of HIV in different groups. The task force addressed stigma, barriers to accessing care and racial/ethnic disparities as obstacles to the use of PrEP by patients and groups at high risk.
Other commenters requested that the USPSTF include a specific meta-analysis examining the effects of PrEP on the risk of sexually transmitted infections in the evidence reviewed for this recommendation.
The task force noted it had reviewed this meta-analysis: "However, because of methodologic limitations of the studies included in the meta-analysis, such as not adjusting for differential STI testing rates and use of self-report to determine baseline STI rates, it was not included in the body of evidence considered for this recommendation."
Lastly, in response to commenters, the USPSTF added the American College of Obstetricians and Gynecologists' opinion on the use of PrEP to the Recommendations of Others(www.uspreventiveservicestaskforce.org) section.
"Clinicians have the opportunity to protect patients at high risk for HIV by offering PrEP," USPSTF member Seth Landefeld, M.D., said in the release. "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."
The AAFP's Commission on Health of the Public and Science plans to review the USPSTF's final recommendation statements and evidence summaries and will determine the Academy's stance on the recommendation.
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