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Preexposure Prophylaxis for the Prevention of HIV Infection: US Preventive Services Task Force Recommendation Statement

Author/s: 
US Preventive Services Task Force

Abstract

IMPORTANCE:

An estimated 1.1 million individuals in the United States are currently living with HIV, and more than 700 000 persons have died of AIDS since the first cases were reported in 1981. In 2017, there were 38 281 new diagnoses of HIV infection reported in the United States; 81% of these new diagnoses were among males and 19% were among females. Although treatable, HIV infection has no cure and has significant health consequences.

OBJECTIVE:

To issue a new US Preventive Services Task Force (USPSTF) recommendation on preexposure prophylaxis (PrEP) for the prevention of HIV infection.

EVIDENCE REVIEW:

The USPSTF reviewed the evidence on the benefits of PrEP for the prevention of HIV infection with oral tenofovir disoproxil fumarate monotherapy or combined tenofovir disoproxil fumarate and emtricitabine and whether the benefits vary by risk group, population subgroup, or regimen or dosing strategy; the diagnostic accuracy of risk assessment tools to identify persons at high risk of HIVacquisition; the rates of adherence to PrEP in primary care settings; the association between adherence and effectiveness of PrEP; and the harms of PrEP when used for HIV prevention.

FINDINGS:

The USPSTF found convincing evidence that PrEP is of substantial benefit in decreasing the risk of HIV infection in persons at high risk of HIV acquisition. The USPSTF also found convincing evidence that adherence to PrEP is highly associated with its efficacy in preventing the acquisition of HIV infection; thus, adherence to PrEP is central to realizing its benefit. The USPSTF found adequate evidence that PrEP is associated with small harms, including kidney and gastrointestinal adverse effects. The USPSTF concludes with high certainty that the magnitude of benefit of PrEP with oral tenofovir disoproxil fumarate-based therapy to reduce the risk of acquisition of HIV infection in persons at high risk is substantial.

CONCLUSIONS AND RECOMMENDATION:

The USPSTF recommends offering PrEP with effective antiretroviral therapy to persons at high risk of HIV acquisition. (A recommendation).

Keywords 
United States HIV HIV prevention

Submit a Suggestion for a New Evidence Review

What health care decisions are you struggling with? Would a review of the scientific evidence help inform this decision? Share your ideas with the Agency for Healthcare Research and Quality's (AHRQ) Evidence-based Practice Center (EPC) Program. AHRQ will use these ideas to determine the focus of its evidence reports for next fiscal year (i.e., AHRQ can provide an evidence report at no cost). Your input is important!

Propose your evidence report topics by June 7.

Keywords 
primary health care evidence-based medicine

A Systematic Review of Trials to Improve Child Outcomes Associated With Adverse Childhood Experiences

Author/s: 
Marie-Mitchell, Ariane, Kostolansky, Rashel

Context

The purpose of this systematic literature review was to summarize current evidence from RCTs for the efficacy of interventions involving pediatric health care to prevent poor outcomes associated with adverse childhood experiences measured in childhood (C-ACEs).

Evidence acquisition

On January 18, 2018, investigators searched PubMed, PsycInfo, SocIndex, Web of Science, Cochrane, and reference lists for English language RCTs involving pediatric health care and published between January 1, 1990, and December 31, 2017. Studies were included if they were (1) an RCT, (2) on a pediatric population, and (3) recruited or screened based on exposure to C-ACEs. Investigators extracted data about the study sample and recruitment strategy, C-ACEs, intervention and control conditions, intermediate and child outcomes, and significant associations reported.

Evidence synthesis

A total of 22 articles describing results of 20 RCTs were included. Parent mental illness/depression was the most common C-ACE measured, followed by parent alcohol or drug abuse, and domestic violence. Most interventions combined parenting education, social service referrals, and social support for families of children aged 0–5years. Five of six studies that directly involved pediatric primary care practices improved outcomes, including three trials that involved screening for C-ACEs. Eight of 15 studies that measured child health outcomes, and 15 of 17 studies that assessed the parent–child relationship, demonstrated improvement.

Conclusions

Multicomponent interventions that utilize professionals to provide parenting education, mental health counseling, social service referrals, or social support can reduce the impact of C-ACEs on child behavioral/mental health problems and improve the parent–child relationship for children aged 0–5years.

Keywords 
adverse childhood experience child child abuse psychology of violence physical abuse

The 10 Building Blocks of High-Performing Primary Care

Author/s: 
Bodenheimer, Thomas, Ghorob, Amireh, Willard-Grace, Rachel, Grumbach, Kevin

Our experiences studying exemplar primary care practices, and our work assisting other practices to become more patient centered, led to a formulation of the essential elements of primary care, which we call the 10 building blocks of high-performing primary care. The building blocks include 4 foundational elements-engaged leadership, data-driven improvement, empanelment, and team-based care-that assist the implementation of the other 6 building blocks-patient-team partnership, population management, continuity of care, prompt access to care, comprehensiveness and care coordination, and a template of the future. The building blocks, which represent a synthesis of the innovative thinking that is transforming primary care in the United States, are both a description of existing high-performing practices and a model for improvement.

Keywords 
medical physician’s practice patterns practice management primary health care

Gen-Equip: Genetics Education for Primary Care

About us

The partners in this project currently work in six different European countries.  We have partners with expertise in primary care practice, genetics and adult education, as well as a patient support organisation.  The project was originally designed by Professor Heather Skirton, who has a background in nursing, midwifery and genetic counselling, and Dr Isa Houwink, a GP from the Netherlands.

Keywords 
genetics primary care education of patients health literacy

Proton‐Pump Inhibitors and Long‐Term Risk of Community‐Acquired Pneumonia in Older Adults

Author/s: 
Zirk-Sadowski, Jan, Masoli, Jane A., Delgada, Joao, Hamilton, Willie, Strain, W. David, Henley, William, Melzer, David, Ble, Alessandro

Objectives

To estimate associations between long‐term use of proton pump inhibitors (PPIs) and pneumonia incidence in older adults in primary care.

Design

Longitudinal analyses of electronic medical records.

Setting

England

Participants

Individuals aged 60 and older in primary care receiving PPIs for 1 year or longer (N=75,050) and age‐ and sex‐matched controls (N=75,050).

Measurements

Net hazard ratios for pneumonia incidence in Year 2 of treatment were estimated using the prior event rate ratio (PERR), which adjusts for pneumonia incidence differences before initiation of treatment. Inverse probability weighted models adjusted for 78 demographic, disease, medication, and healthcare usage measures.

Results

During the second year after initiating treatment, PPIs were associated with greater hazard of incident pneumonia (PERR‐adjusted hazard ratio=1.82, 95% confidence interval=1.27–2.54), accounting for pretreatment pneumonia rates. Estimates were similar across age and comorbidity subgroups. Similar results were also obtained from propensity score– and inverse probability–weighted models.

Conclusion

In a large cohort of older adults in primary care, PPI prescription was associated with greater risk of pneumonia in the second year of treatment. Results were robust across alternative analysis approaches. Controversies about the validity of reported short‐term harms of PPIs should not divert attention from potential long‐term effects of PPI prescriptions on older adults.

Keywords 
pneumonia primary care proton pump inhibitors

Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices

Author/s: 
Fleming, Michael F., Barry, Kristen L., Manwell, Linda B., Johnson, Kristen, London, Richard

OBJECTIVE:

Project TrEAT (Trial for Early Alcohol Treatment) was designed to test the efficacy of brief physician advice in reducing alcohol use and health care utilization in problem drinkers.

DESIGN:

Randomized controlled clinical trial with 12-month follow-up.

SETTING:

A total of 17 community-based primary care practices (64 physicians) located in 10 Wisconsin counties.

PARTICIPANTS:

Of the 17695 patients screened for problem drinking, 482 men and 292 women met inclusion criteria and were randomized into a control (n=382) or an experimental (n=392) group. A total of 723 subjects (93%) participated in the 12-month follow-up procedures.

INTERVENTION:

The intervention consisted of two 10- to 15-minute counseling visits delivered by physicians using a scripted workbook that included advice, education, and contracting information.

MAIN OUTCOME MEASURES:

Alcohol use measures, emergency department visits, and hospital days.

RESULTS:

There were no significant differences between groups at baseline on alcohol use, age, socioeconomic status, smoking status, rates of depression or anxiety, frequency of conduct disorders, lifetime drug use, or health care utilization. At the time of the 12-month follow-up, there were significant reductions in 7-day alcohol use (mean number of drinks in previous 7 days decreased from 19.1 at baseline to 11.5 at 12 months for the experimental group vs 18.9 at baseline to 15.5 at 12 months for controls; t=4.33; P<.001), episodes of binge drinking (mean number of binge drinking episodes during previous 30 days decreased from 5.7 at baseline to 3.1 at 12 months for the experimental group vs 5.3 at baseline to 4.2 at 12 months for controls; t=2.81; P<.001), and frequency of excessive drinking (percentage drinking excessively in previous 7 days decreased from 47.5% at baseline to 17.8% at 12 months for the experimental group vs 48.1% at baseline to 32.5% at 12 months for controls; t=4.53; P<.001). The chi2 test of independence revealed a significant relationship between group status and length of hospitalization over the study period for men (P<.01).

CONCLUSIONS:

This study provides the first direct evidence that physician intervention with problem drinkers decreases alcohol use and health resource utilization in the US health care system.

Keywords 
alcohol alcoholism counseling primary health care
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