New USPSTF Guidelines for HIV Screening and Preexposure Prophylaxis (PrEP)

In the June 11, 2019, issue of JAMA, the US Preventive Services Task Force (USPSTF) updates its 2013 recommendations on HIV screening and issues its first published guidance on the prevention of HIV infection with preexposure prophylaxis (PrEP).1-7 As in 2013, the USPSTF provides a grade A recommendation for routine, voluntary HIV screening among all persons aged 15 to 65 years, all pregnant women, and all individuals at high risk of infection. The USPSTF assigns a grade A for a new recommendation to offer PrEP to all persons at high risk of HIV infection, corroborating similar clinical practice guidelines issued in 2014 and 2017 by the US Centers for Disease Control and Prevention8 and the International Antiviral Society–USA panel.9 These new recommendations bolster what we already knew: the evidence in support of expanded HIV screening and PrEP is strong. However, the guidelines do not address some of the hard lessons we are learning: screening and PrEP are merely points of entry to a pathway of care that is riddled with obstacles and opportunities for failure. The significance of the new recommendations lies in the large number of individuals in the United States whose insurance coverage for HIV preventive services, notably PrEP, will be favorably affected. Most US public and private insurers use the USPSTF grading scheme to guide their decisions about which preventive services to cover. The 2010 Patient Protection and Affordable Care Act (ACA) codified this process, instituting formal requirements and incentives for coverage of preventive services that achieve a grade A or B recommendation from the USPSTF.10 Since the release of the USPSTF’s grade A recommendation for HIV screening in 2013, most individuals in the United States with health insurance have had access to routine HIV testing at no out-of-pocket cost. The new recommendations will open doors to PrEP and its associated services. This is a big step forward and is sufficient cause to applaud the USPSTF for its leadership. Early detection and treatment of HIV infection was a good idea in 2013; it is an even better idea today. The new recommendations provide a comprehensive update of the many randomized clinical trials and cohort studies that have been conducted in the last 6 years on a global study population that, taken as a whole, includes more than 70 000 people living with HIV. The USPSTF reaffirms the unequivocal benefits of early antiretroviral therapy (ART) initiation and viral suppression, in terms of increased survival of individuals with HIV and in terms of reduced HIV transmission to partners. Routine testing is the most effective gateway through which individuals may be triaged to appropriate follow-up care. Persons with newly diagnosed HIV infections can be linked immediately to social support services, provision of ART, and appropriate counseling to protect their partners. Persons at high risk who have negative HIV test results can be referred either for initiation of PrEP (with repeated quarterly HIV screening) or simply for frequent repeated HIV screening; persons at lower risk who have negative HIV test results can be provided the opportunity to ask questions and then referred for occasional rescreening. The frequency of repeated HIV screening for persons not receiving PrEP remains a research question. Less well explicated in the new recommendations is the HIV continuum of care—the so-called HIV cascade—and our growing appreciation of how failure to retain patients at every step of the pathway from detection to viral suppression weakens our effort to realize the full, life-saving + Related articles at jama.com, jamainternalmedicine.com