Abstract
IntroductionGuidelines for pre-exposure prophylaxis (PrEP) provide criteria to identify individuals at higher risk of HIV infection. We compared the ability to predict HIV seroconversion of four guidelines: the World Health Organization (WHO), the United States Public Health Service and Centers for Disease Control and Prevention (US CDC), the European AIDS Clinical Society (EACS) and the Portuguese National Health Service (PNHS).AimWe aimed to measure the association between guideline-specific eligibility and HIV seroconversion.MethodsWe studied 1,254 participants from the Lisbon Cohort of men who have sex with men with at least two evaluations between March 2014 and March 2018, corresponding to 1,724.54 person-years (PY) of follow-up. We calculated incidence rates (IR) according to each guideline eligibility definition and incident rate ratios (IRR) to test the association between eligibility at baseline and HIV seroconversion.ResultsWe found 28 incident cases (IR: 1.62/100 PY; 95% confidence interval (CI) 1.12–2.35). Guidelines’ sensitivity varied from 60.7% (EACS) to 85.7% (PNHS) and specificity varied from 31.8% (US CDC) to 51.5% (EACS). IR was highest among those defined as eligible by the PNHS guideline (2.46/100 PY; IRR = 4.61; 95% CI: 1.60–13.27) and lowest for the WHO guideline (1.89/100 PY; IRR = 1.52; 95% CI: 0.69–3.35).ConclusionsBeing identified as eligible for PrEP was associated with a higher risk of infection. The magnitude of risk varied according to the guideline used. However, the number of HIV infections identified among ineligible participants highlights the potential for missing people who need PrEP.
Highlights
Guidelines for pre-exposure prophylaxis (PrEP) provide criteria to identify individuals at higher risk of human immunodeficiency virus (HIV) infection
The Portuguese National Health Service (PNHS) guidelines were able to identify the highest number of seroconverters (85.7%) and showed the strongest association with seroconversion (IRR = 4.61; 95% confidence interval (CI): 1.60–13.27)
We were not able to determine eligibility according to the PNHS guidelines for the period from inception to March 2014, which was possible for the other three guidelines. When they were evaluated using the entire period, the direction and magnitude of the associations for the World Health Organization (WHO), United States (US) Centers for Disease Control and Prevention (CDC), and European AIDS Clinical Society (EACS) guidelines were similar to the results presented here
Summary
Guidelines for pre-exposure prophylaxis (PrEP) provide criteria to identify individuals at higher risk of HIV infection. One key aspect of a public health approach to combination prevention is the ability to identify those at higher risk correctly [4]. While some strategies, such as condom use, are intended to reach the highest number of individuals, other strategies, such as PrEP, primarily target individuals at higher risk to maximise cost-effectiveness [5]. Several screening tools and guidelines exist that help healthcare providers identify high-risk individuals based on HIV predictors [6,7,8,9] They were associated with moderate discrimination in predicting incident HIV infections [10]
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More From: Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin
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