New Recommendations for Earlier HIV Screening and PrEP for Women

The American College of Obstetricians and Gynecologists last week issued 2 new recommendations on screening and prevention of HIV in women. The first matches the CDC's recommendation that HIV screening should start at age 13 and should be offered at least annually to at-risk women. The second advises that pre-exposure prophylaxis (PrEP) -- using antiretroviral medications such as Truvada to prevent HIV infection -- may be a useful tool for women at highest risk, including those with HIV positive male partners.

Below is an edited excerpt from an American College of Obstetricians and Gynecologists press release summarizing the new recommendations.

New Guidelines Address Screening, Prevention of HIV in Women

Washington, DC -- April 21, 2014 -- Reflecting a growing emphasis on the importance of preventive care for women, the American College of Obstetricians and Gynecologists (the College) today released two Committee Opinions on human immunodeficiency virus (HIV) in women: One lowering the recommended age for HIV screening and one addressing prevention of HIV transmission through use of prophylaxis.

Because ob-gyns often provide primary and preventive care to their patients, they are ideally suited to play an important role in promoting HIV screening and prevention for women. Notably, the College released the new recommendations during the Centers for Disease Control and Prevention’s STD Awareness Month.

In 2010 and 2011, approximately 10,000 women in the United States were diagnosed with HIV. Unfortunately, almost one in five people with HIV are unaware of their infection. Lack of diagnosis can lead to delays in treatment, increased risk of infecting others, and other health care challenges.

The College mirrors the Centers for Disease Control and Prevention’s recommendation that all females ages 13 to 64 be tested at least once in their lifetime; previous guidelines recommended that testing begin at age 19. Annual re-testing is recommended, based on individual risk factors.

For example, the College recommends that repeat HIV testing be offered at least annually to women who:

• Are injection-drug users or partners of injection-drug users;
• Exchange sex for money or drugs;
• Have had sex with men who have sex with men since their most recent HIV test; or
• Have had more than one sex partner since their most recent HIV test.

"As physicians, our role does not end with HIV testing," said Ruth Morgan Farrell, MD, MA, a member of The Colleges Committee on Gynecologic Practice, which developed the Committee Opinion. "If a patient has a positive HIV test, the ob-gyn should continue counseling the patient, referring her for appropriate clinical and supportive care."

For women who are at highest risk of HIV infection, pre-exposure prophylaxis (PrEP) may be a useful tool in combination with other HIV prevention methods, according to the second Committee Opinion, "Preexposure Prophylaxis for the Prevention of Human Immunodeficiency Virus." PrEP is the once-daily dose of antiretroviral medications to HIV-negative individuals who are a high risk of becoming infected. PrEP has been shown to be effective in decreasing transmission rates, with reportedly mild adverse effects.

The new guideline clarifies that potential candidates for PrEP are women not infected with HIV who have a male sexual partner who is HIV positive and/or women who engage in sexual activity within a high HIV-prevalence area or social network, and who have one or more of the following risk factors:

• Inconsistent or no condom use;
• Diagnosis of sexually transmitted infections;
• Exchange of sex for commodities;
• Use of intravenous drugs or alcohol dependence or both; and/or
• Partners of unknown HIV status with any of the factors previously listed.

In discussing the new guidelines about PrEP, Kevin A. Ault, MD, a member of the College’s Committee on Gynecologic Practice, which developed the Committee Opinion, emphasized the importance of physician counseling to reduce the patient’s risk: "Although PrEP may be an excellent option for women who are at the highest risk of acquiring HIV, as ob-gyns, we should continue to stress the importance of risk reduction, like safe-sex practices, especially consistent condom use."

For example, risk reduction conversations should also include education, counseling about testing, discussions about increased condom use, and other behavioral interventions. Ob-gyns involved in the care of women using PrEP must also reinforce the importance of adhering to the daily medication regimen.

The CDC’s guidance for PrEP is likely to evolve in the coming years, and ob-gyns should remain aware of new developments in this area.

Committee Opinion #595 "Preexposure Prophylaxis for the Prevention of Human Immunodeficiency Virus" and Committee Opinion #596 "Routine Human Immunodeficiency Virus Screening" will be published in the May issue of Obstetrics & Gynecology.

4/29/14

Sources

American College of Obstetricians and Gynecologists. New Guidelines Address Screening Prevention of HIV in Women. Press release. April 21, 2014.

American College of Obstetricians and Gynecologists. Preexposure Prophylaxis for the Prevention of Human Immunodeficiency Virus. Committee Opinion Number 595. May 2014.

American College of Obstetricians and Gynecologists. Routine Human Immunodeficiency Virus Screening. Committee Opinion Number 596. May 2014.