Update to PrEP Recommendations Include Long-Acting Shot

The United States Preventative Service Task Force (USPSTF) recently released updated recommendations on Pre-Exposure Prophylaxis for preventing the sexual transmission of HIV. The recommendations add additional medications, including a long-acting injectable, to the possible regimens and gives these strategies an A grade which should help eligible individuals get insurance coverage for PrEP.

PrEP was introduced in 2012 when the FDA approved Truvada, a daily pill for people who are HIV-negative but at higher risk of infection. If taken as directed, Truvada can lower the risk of contracting HIV by up to 99%. In 2019, the USPSTF gave Truvada as PrEP an A grade. Since that time new medications for PrEP have been approved including generic versions of Truvada, Descovy (another oral medication), and cabotegravir (an injectable drug given every two months that is marketed as Apretude). The updated recommendations released last week add all of these options to the A grade.

The Task Force makes recommendations based on weighing the benefits and harms of a medical intervention. While it does not consider insurance coverage, the grades have implications because the Affordable Care Act says that private insurers must cover preventative services that receive an A or B grade with no co-pay or deductible. (That provision of the ACA is being challenged in court by a group of businesses and individuals who say that they should not be forced to pay for preventative services, like PrEP, that violate their religious beliefs. A lower court in Texas has ruled in their favor and the case is now being appealed.)

The Task Force’s recommendations also include a discussion of who should have access to PrEP. They suggest that providers ask all patients about their sexual and injection drug use history and offer PrEP to sexually active adults and adolescents who have engaged in anal or vaginal sex in the past 6 months, and:

• have a sexual partner with HIV (especially one with unknown or detectable viral load)
• have had a bacterial STI within the past six months
• do not use condoms or use them inconsistently
• engage in transactional sex

The recommendations also suggest that clinicians offer PrEP to anyone who injects drugs or has a partner with HIV who injects drugs.

These recommendations vary slightly from CDC guidelines which suggest providers discuss PrEP with all sexually active adults and adolescents and prescribe to anyone who asks for it.

Uptake of PrEP since it was introduced has been disappointing to many public health experts who see this prevention strategy as key to ending the epidemic. The CDC estimates that 1.2 million people are eligible for PrEP but only 30% of them are actually using it. Moreover, there are significant disparities in who is accessing this prevention method. While 78% of white people who are eligible for PrEP are taking it, only 11% of eligible Black people, 12% of eligible women, and 21% of eligible Latinas/os are using PrEP.

As the Task Force explained in an accompanying article for the Journal of the American Medical Association (JAMA), “PrEP is the ultimate implementation science challenge. At more than 90 percent efficacy when used properly, the only barrier to drastically reducing HIV incidence in the U.S. is addressing the systemic low coverage.”