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USPSTF Updates HIV Screening Guidelines to Include PrEP Recommendation

NEW YORK (360Dx) — The US Preventive Services Task Force today updated its recommendations for HIV infection screening, advising screening for adolescents and adults ages 15 to 65 years given the substantial benefits of early detection and treatment.

The USPSTF also recommends screening for individuals at increased risk of HIV infection regardless of age, as well as all pregnant women whose HIV status is unknown. The guidelines appear in the Journal of the American Medical Association and reaffirm the agency's previous recommendation on HIV screening issued in 2013.

In the latest guidelines, however, the USPSTF has added its support for preexposure prophylaxis (PrEP) — the first time the task force has published a recommendation on the topic.

The USPSTF said that its latest recommendations are based on systematic evidence reviews examining the benefits and harms of screening for HIV infection in nonpregnant adolescents and adults; the yield of screening for HIV infection at different intervals; the effects of initiating antiretroviral therapy (ART) at a higher versus lower CD4 count; and the longer term harms associated with currently recommended ART regimens.

It also reviewed the evidence on the benefits and harms of screening for HIV infection in pregnant persons; the yield of repeat screening for HIV at different intervals during pregnancy; the effectiveness of currently recommended ART regimens for reducing mother-to-child transmission of HIV infection; and the harms of ART during pregnancy to the mother and infant.

The USPSTF noted that although there are some potential harms associated with ART treatment — including neuropsychiatric, renal, and hepatic harms, as well as an increased risk of preterm birth in pregnant women — they are limited and far outweighed by the net benefits of screening and early disease treatment.

Currently recommended HIV tests are highly accurate and early initiation of ART and viral suppression has been shown to reduce the risk of clinical progression to AIDS, AIDS-related events, and death, the task force said. Further, ART reduces disease transmission, both between sex partners and from mother to child.

"The overall magnitude of the benefit of screening for HIV infection in adolescents, adults, and pregnant women is substantial," the USPSTF stated. As such, HIV screening in individuals ages 15 to 65, those at high risk of infection, and pregnant woman continues to receive the agency's grade A recommendation, its highest.

Citing the importance of prevention in reducing HIV incidence, it also recommends the use of condoms and intensive behavioral counseling for all sexually active adolescents and for adults at increased risk for sexually transmitted infections. Importantly, the USPSTF stated that PrEP — the administration of daily antiretroviral medication before exposure — has proven effective in controlling HIV infection and is therefore recommended to those at high risk of infection.

In an editorial appearing in JAMA Network Open, Massachusetts General Hospital's Rochelle Walensky and Yale University's David Paltiel wrote that the PrEP recommendation is expected to favorably affect the large number of people in the US whose health insurance covers HIV preventative services.

"Most US public and private insurers use the USPSTF grading scheme to guide their decisions about which preventive services to cover," they wrote. "The new recommendations will open doors to PrEP and its associated services. This is a big step forward."

The USPSTF did not provide specific guidelines for repeat HIV screening, but said that it is reasonable for those at increased risk for HIV infection, as well as those who live or receive medical care in a high-prevalence setting such as a correctional facility or sexually transmitted disease clinic.

Mirroring guidelines from the US Centers for Disease Control and Prevention, the USPSTF said that screening should only be performed with a patient's consent, or  should be done on an opt-out basis in which testing is performed unless specifically declined by the patient.