The Medical Care Criteria Committee (MCCC) of the New York State Department of Health (NYSDOH) AIDS Institute recently released guidelines on preexposure prophylaxis (PrEP), PrEP to Prevent HIV Acquisition. This clinically focused guideline for the administration and management of PrEP for prevention of HIV infection supports New York State’s End the Epidemic (ETE) initiative, a three-point plan set forth by Governor Cuomo in 2014 to end the AIDS epidemic in New York State. ETE aims to decrease the number of new HIV infections to 750 (from an estimated 3000) by 2020, and HIV prevalence will be reduced for the first time ever in New York State. The plan focuses on three key actions:
- Identifying people with HIV infection who have not received a diagnosis and linking them to HIV care;
- Linking and retaining people diagnosed with HIV to healthcare to maximize virus suppression so that they remain healthy and do not transmit the virus; and
- Facilitating access to PrEP for people at high risk of acquiring HIV to prevent infections.
PrEP is a highly effective primary prevention strategy for individuals at increased risk for HIV acquisition. The NYSDOH AIDS Institute guideline committee recommends PrEP as part of a comprehensive HIV prevention strategy that includes counseling on safer sex and safer injection practices. PrEP consists of a daily tablet of combined tenofovir disoproxil fumarate/emtricitabine (TDF/FTC; Truvada for PrEP™). The significant effectiveness of PrEP in reducing HIV acquisition has been demonstrated in clinical trials and through implementation in the clinical setting.
Guideline-Based Approach to Implementing PrEP in Clinical Practice
The NYSDOH AIDS Institute PrEP guideline takes a step-by-step approach to implementing PrEP in clinical practice, starting with guidance on screening to identify candidates for PrEP. Several checklists are provided for clinicians; these include pre-prescription evaluation, patient education, and PrEP management, all of which are available in printable pocket guides as well. The guideline is written for a broad range of clinicians, including primary care practitioners and specialists in infectious diseases, general internal medicine, pediatrics/adolescent medicine, family medicine, and gynecology/obstetrics. In short, it is designed for use by all care providers who have the opportunity to address sexual health and HIV prevention with their patients. The PrEP Guideline is a tool for all clinicians to understand the benefits, use, and management of PrEP; to educate their patients; and to help their patients protect themselves from HIV infection.
Candidates for PrEP
When used as prescribed, PrEP is > 90% effective in reducing risk acquired through sexual activity, and > 70% effective in reducing risk acquired through injection drug use.[1,3,6] PrEP use has been rising steadily over the past 4 years, but PrEP awareness and uptake are not aligned with need. In the United States, 44% of new HIV infections occur among black people, but 70% of PrEP users are white and only 10% are black. There is a critical need to increase the use of PrEP among individuals who stand to benefit from it the most. Early adopters and those willing to seek out PrEP providers are likely to obtain PrEP from HIV care providers and to be adherent with PrEP. Expanding the use of PrEP beyond early adopters will challenge clinicians to identify those who are more reluctant, may not recognize their risk, may have barriers to considering and obtaining PrEP, or may not know about this HIV prevention method.
Author: Joseph P. McGowan, MD