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Clin Infect Dis. 2019 Jan 28. doi: 10.1093/cid/ciz046. [Epub ahead of print]

US Guideline Criteria for HIV Pre-Exposure Prophylaxis: Clinical Considerations and Caveats.

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Department of Psychology, George Washington University, Washington, DC, USA.
Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard University, Boston, MA, USA.
The Fenway Institute, Fenway Health, Boston, MA, USA.
Department of Population Medicine, Harvard Medical School, Harvard University, Boston, MA, USA.
Miriam Hospital, Providence, RI, USA.
Warren Alpert Medical School, Brown University, Providence, RI, USA.
Social and Behavioral Sciences Department, Yale School of Public Health, Yale University, New Haven, CT, USA.
Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA.


Clinical guidelines for HIV pre-exposure prophylaxis (PrEP) developed by the US Centers for Disease Control and Prevention have been instrumental to the implementation of PrEP in medical practices throughout the country. However, the eligibility criteria contained within may inadvertently limit PrEP access for some patients. We describe key considerations and caveats surrounding these criteria: (1) promotion of a selective vs. universal approach to sexual health education involving PrEP; (2) misalignment between criteria stated in the table and text boxes; (3) problematic categorization and confounding of sexual orientation, gender identity, and risk behavior; (4) underemphasis of network/community-level drivers of HIV transmission; (5) oversimplification of serodiscordant risk; and (6) lack of clarity surrounding the relevance of condoms to PrEP eligibility. We offer concrete recommendations to address the identified issues and strengthen future iterations of the guidelines, applying these recommendations in an alternative table of "criteria."


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