Journal Article Annotations
2023, 3rd Quarter
Annotations by John A R Grimaldi, MD, Mary Ann Cohen, MD, FACLP, Kelly Cozza, MD, DFAOA, FACLP, Luis Pereira, MD
This systematic review is an update from 2019 US Preventive Services Task Force (USPSTF) recommendations for use of HIV pre-exposure prophylaxis (PrEP) to prevent acquisition of HIV and diagnostic accuracy of instruments for predicting HIV infection. The study confirmed the 2019 USPSTF findings of the effectiveness of oral tenofovir disoproxil fumarate (TDF) either alone, or in combination with oral emtricitabine (FTC), in preventing acquisition of HIV in men who have sex with men (MSM), transgender women, heterosexual men, and women at risk from vaginal receptive sex, compared to placebo or no pre-exposure prophylaxis (PrEP). In MSM, oral tenofovir alafenamide (TAF) combined with FTC was noninferior to, and potentially had increased efficacy, compared to TDF/FTC in preventing HIVinfection. Compared to TDF/FTC, TAF/FTC was associated with better outcomes regarding bone mineral density, and worse outcomes regarding weight gain and lipid parameters. Cabotegravir administered as a long-acting, injectable formulation, performed better than TDF/FTC in preventing HIV acquisition in MSM and transgender women. Instruments for predicting incident HIV showed moderate to high discrimination and require further validation.
Strengths and limitations:
High quality databases were used and only randomized clinical trials were reviewed in the study. The studies available for review had several limitations. Non-English-language articles were excluded, leading to possible publication bias. Additionally, only one trial, from Thailand, included persons who inject drugs and all trials involving people at risk from heterosexual sex were conducted in Africa, thus limiting generalizability. Adolescents were not enrolled in any trials and no trials measured effect of PrEP on quality of life, anxiety, or worry about acquiring HIV. The use of TAF/FTC has not been studied in women at risk from receptive vaginal sex and studies on the safety and efficacy of all forms of PrEP in pregnancy are limited.
Relevance: This study guides progress towards the federal government’s ambitious goal of ending HIV by 2030. Expanding available options will increase access to and uptake of PrEP among persons at risk for acquiring HIV. The requirement for daily adherence to medications, the stigma associated with taking oral HIV medications, and the risk of potentially serious side effects have been barriers to more widespread use of TDF/FTC. The addition of TAF/FTC and long-acting, injectable cabotegravir could mark significant therapeutic progress in ending this four-decade long epidemic.
Using a retrospective cohort design, this study examined the prevalence of HIV among people who used mental health services in four boroughs in London with high rates of HIV. Cases were identified by linking mental health electronic records to a national HIV and AIDS reporting system between 2007 and 2018. The overall HIV prevalence of people presenting for mental health services was approximately 2.5 times greater than found in the general population in the same borough. The prevalence remained high even when people were excluded who did not have a recorded mental health diagnosis. HIV prevalence for people with substance use disorders was 3.77%. Substance use disorders were the most common diagnoses at 18%, followed by mood disorders at 15%, and neurotic and stress-related disorders at 13%.
Strengths and limitations:
The study’s major strength was its use of routinely collected data. This reduces sampling selection bias and bias due to missing data. The effect of stigma on willingness to participate in primary data collection research is another advantage of using this electronic data set. Accuracy of identifying the prevalence of HIV was improved by using a national HIV reporting system. This study has several limitations. The data are restricted to people presenting for mental health services and HIV testing services. People with mental health disorders may be less willing to obtain HIV testing. The sample is also restricted to a specific area of London with a high prevalence of HIV. Findings may not be generalizable to other geographic areas and to areas with low HIV prevalence.
People with mental health disorders are at higher risk for cardiovascular disease, metabolic syndrome, and early mortality compared to people without psychiatric diagnoses. These correlations have led to increased research of these comorbidities, but there is less understanding of the risk for HIV among persons with mental illness. This study supports the need for greater attention to infectious diseases such as HIV and more broadly to sexually transmitted and blood-borne diseases in psychiatric populations. Sexual health should be routinely addressed in both medical and mental health settings.
This US Preventive Services Task Force (USPSTF) recommendation gives a Grade A rating to the use of oral and injectable medication to prevent the acquisition of HIV through sexual contact and the use of needles to inject drugs. This places PrEP among other Grade A recommendations such as screening for cervical and colorectal cancer and tobacco smoking cessation. This article also offers practical information about PrEP to clinicians who treat persons at risk for HIV acquisition. The USPSTF emphasizes the importance of taking a sexual and drug history on all patients, and guidance for identifying those persons who are at increased risk of acquiring HIV. Guidance is provided for implementation of PrEP and the risks and benefits of the FDA-approved medications indicated for use as PrEP: oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC), oral tenofovir alafenamide/emtricitabine (TAF/FTC), and long-acting injectable cabotegravir.