This Practice Advisory was developed by the American College of Obstetricians and Gynecologists in collaboration with Okeoma Mmeje, MD, MPH, Eve Zaritsky, MD, and Jenell S. Coleman, MD, MPH.
This Practice Advisory serves as an update to Committee Opinion No. 595, Preexposure Prophylaxis for the Prevention of Human Immunodeficiency Virus, originally published in 2014 1 .
Background
In 2021, the Centers for Disease Control and Prevention (CDC) released updated guidance on preexposure prophylaxis (PrEP) for the prevention of human immunodeficiency virus (HIV) infection in the United States 2 . For the first time, the CDC recommends that all sexually active adults and adolescents be informed about PrEP for prevention of HIV acquisition.
Obstetrician–gynecologists have the potential to play an important role in increasing the awareness of PrEP in their sexually active patients and use among their patients at substantial risk of HIV infection. Access to and awareness of PrEP varies by age, sex, gender identity, and race/ethnicity 3 . For example, in 2019, heterosexual cisgender women accounted for 16% of new HIV diagnoses in the United States 4 , yet only 10% of those women who could benefit from PrEP received a prescription for it 3 . Other barriers to PrEP include limited transportation or work schedule constraints that may make accessing health care services difficult 5 , in addition to clinicians who lack knowledge of and comfort with PrEP and continued stigma surrounding HIV. Transgender individuals may face transphobia and discrimination by the healthcare system as well as additional social and economic barriers 3 . Adolescent patients may face other challenges, including confidentiality as it relates to explanation of benefits statements, and consent barriers, as many states do not specify PrEP as a service to which a minor adolescent can consent. For guidance on confidentiality in the provision of adolescent health care, see ACOG Committee Opinion No. 803, Confidentiality in Adolescent Health Care 6 and the ACOG-endorsed Society for Adolescent Health and Medicine and the American Academy of Pediatrics’ Position Statement, Confidentiality Protections for Adolescents and Young Adults in the Health Care Billing and Insurance Claims Process 7 .
Updated ACOG Recommendation
Based on the CDC’s new clinical guidance and its supporting evidence of benefit, the American College of Obstetricians and Gynecologists (ACOG) recommends that obstetrician–gynecologists discuss PrEP with all sexually active adolescent and adult patients, rather than providing this information to only those considered at substantial risk of HIV infection.
Implementation Considerations
The CDC’s updated guidance simplifies the indications for offering PrEP to those at substantial risk of HIV acquisition Figure 1.
The American College of Obstetricians and Gynecologists recommends clinicians take a comprehensive medical history, including sexual history, as part of a routine well-person visit 8 9 . The CDC suggests taking a sexual history that encompasses the 5 Ps: 1) Partners; 2) Practices; 3) Protection from sexually transmitted infections (STIs); 4) Past history of STIs; and 5) Pregnancy intention (Box 1). See ACOG Committee Opinion No. 811, The Initial Reproductive Health Visit, Box 3 for sexual history questions adapted for the adolescent patient 9 .
Box 1.
The Five Ps Approach for Health Care Clinicians Obtaining Sexual Histories (CDC)
- Partners
- “Are you currently having sex of any kind?”
- “What is the gender(s) of your partner(s)?”
- Practices
- “To understand any risks for STIs, I need to ask more specific questions about the kind of sex you have had recently.”
- “What kind of sexual contact do you have or have you had?”
- “Do you have vaginal sex, meaning ‘penis in vagina’ sex?”
- “Do you have anal sex, meaning ‘penis in rectum/anus’ sex?”
- “Do you have oral sex, meaning ‘mouth on penis/vagina’?”
- Protection from STIs
- “Do you and your partner(s) discuss prevention of STIs and human immunodeficiency virus (HIV)?”
- “Do you and your partner(s) discuss getting tested?”
- For condoms:
- “What protection methods do you use? In what situations do you use condoms?”
- The CDC suggests the inclusion of the following question: "Are you aware of PrEP, a medicine that can prevent HIV? Have you ever used it or considered using it?"
- Past History of STIs
- “Have you ever been tested for STIs and HIV?”
- “Have you ever been diagnosed with an STI in the past?”
- “Have any of your partners had an STI?”
- Pregnancy Intention
- “Do you think you would like to have (more) children in the future?”
- “How important is it to you to prevent pregnancy (until then)?”
- “Are you or your partner using contraception or practicing any form of birth control?”
- “Would you like to talk about ways to prevent pregnancy?”
Abbreviations: CDC, Centers for Disease Control and Prevention; PrEP, preexposure prophylaxis; STIs, sexually transmitted infections. Modified from Centers for Disease Control and Prevention. STI and HIV infection risk assessment. In: Sexually transmitted infections treatment guidelines, 2021. CDC; 2021. Accessed May 17, 2022. https://www.cdc.gov/std/treatment-guidelines/clinical-risk.htm
When discussing STIs (“Protection from STIs”), the CDC suggests the inclusion of the following question:
Are you aware of PrEP, a medicine that can prevent HIV? Have you ever used it or considered using it?
Also, when discussing protective practices (eg, barrier methods), clinicians can include PrEP as a strategy to prevent HIV. Additional self-screening questions have been developed specifically for women that focus on a patient’s risk over the past 6 months 10 . The CDC recommends that clinicians counsel sexually active women who use contraceptive methods other than condoms about the correct and consistent use of condoms in addition to other prevention strategies such as PrEP 2 . For those individuals not actively trying to achieve a pregnancy via heterosexual relations, PrEP in conjunction with barrier contraception provides an effective HIV prevention strategy.
Preexposure prophylaxis is not intended to be a lifelong prevention strategy. Instead, some individuals can benefit from its use during periods of elevated risk. For up-to-date information on PrEP, including same-day prescribing, regimens (eg, daily oral or injectable PrEP), and clinical follow-up, including guidance for transgender individuals, and pregnant and breastfeeding people, see the CDC’s Preexposure Prophylaxis for the Prevention of HIV Infection in the United States—2021 Update: A Clinical Practice Guideline 2 .
With routine lab monitoring and counseling, PrEP can be safely prescribed by obstetrician–gynecologists and other allied health care professionals. National consultation services such as the PrEPline: National Clinician’s Consultation Center are useful tools. Obstetrician–gynecologists also may use resources such as the National Prevention Information Network’s PrEP Provider Data and Locator Widget to identify clinicians in their communities who prescribe PrEP. If possible, clinicians should work with their infectious disease or public health colleagues to assist patients in accessing same-day or near same-day referrals.
Coverage
With the U.S. Preventive Services Task Force assigning PrEP an “A” grade for HIV risk reduction 11 , most health plans are prohibited from imposing patient cost-sharing on medication, required baseline labs, or monitoring services 12 . Preexposure prophylaxis also is covered by Medicaid. See the “Resources” section for information on patient assistance programs.
Please contact [email protected] with any questions.
Resources
These materials are for information purposes only and are not meant to be comprehensive. Referral to these resources does not imply ACOG's endorsement of the organization, the organization’s website, or the content of the resource. The resources may change without notice.
General PrEP Information
Centers for Disease Control and Prevention: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States—2021 Update: A Clinical Practice Guideline
The updated guideline and supplement reflect the latest science and are intended to help clinicians effectively prescribe all U.S. Food and Drug Administration-approved PrEP medications to patients and increase PrEP use among all people who could benefit.
National Clinician Consultation Center: PrEP Guidelines & Resources
((855) 448-7737 or (855) HIV-PrEP; 9 a.m. to 8 p.m. ET, Monday to Friday)
The National Clinician Consultation Center provides clinicians of all experience levels prompt, expert responses to questions about managing HIV/AIDS, perinatal HIV, pre-exposure prophylaxis, and bloodborne pathogen exposures. They provide online and phone-based consultation in service areas including testing and prevention, treatment, and post-exposure prophylaxis. All of the services are cost-free and confidential.
Locating PrEP Prescribers
Centers for Disease Control and Prevention: National Prevention Information Network PrEP Provider Data and Locator Widget, National Directory of Providers of HIV Pre-Exposure Prophylaxis (PrEP) in the United States
The National Prevention Information Network provides a comprehensive, national directory of public and private clinicians in the U.S. that offer PrEP to prevent HIV infection. The database includes more than 1,800 PrEP providers from all 50 states, as well as U.S. territories.
Information for Patients
Centers for Disease Control and Prevention: PrEP Is for Women
This patient brochure reviews important information on how women and other people who have receptive vaginal sex can stay HIV negative, even if their partner(s) might have HIV. It offers tips on what questions women and other people who have receptive vaginal sex can ask their health care clinicians about PrEP.
U.S. Department of Health and Human Services. HIV.gov, Pre-Exposure Prophylaxis
HIV.gov provides patient-focused information on PrEP, including its safety, what drugs are approved for PrEP, how to obtain PrEP, as well as insurance coverage and patient assistance programs.
Coverage
National Alliance of State and Territorial AIDS Directors: State PrEP Assistance Programs
The site provides a list of state programs that provide medication assistance to PrEP candidates.
The Department of Health and Human Services, Office of Infectious Disease and HIV/AIDS Policy: Ready, Set, PrEP Program
The Ready, Set, PrEP program provides free PrEP HIV-prevention medications to thousands of people living in the United States, including tribal lands and territories, who qualify.
