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Current US Guidelines for Prescribing HIV Pre-exposure Prophylaxis (PrEP) Disqualify Many Women Who Are at Risk and Motivated to Use PrEP

Calabrese, Sarah K. PhDa,b; Willie, Tiara C. PhDb,c,d; Galvao, Rachel W. BAa,e; Tekeste, Mehrit BAa; Dovidio, John F. PhDb,f,g; Safon, Cara B. MPHg,h; Blackstock, Oni MD, MPHb,i; Taggart, Tamara PhD, MPHb,j; Kaplan, Clair MSN, APRN, MHSk; Caldwell, Abigail MSN, APRNk; Kershaw, Trace S. PhDb,g

JAIDS Journal of Acquired Immune Deficiency Syndromes: August 1, 2019 - Volume 81 - Issue 4 - p 395–405
doi: 10.1097/QAI.0000000000002042
Prevention Research

Background: US Centers for Disease Control and Prevention clinical guidelines for HIV pre-exposure prophylaxis (PrEP) are widely used to assess patients' PrEP eligibility. The guidelines include 2 versions of criteria—guidance summary criteria and recommended indications criteria—that diverge in a potentially critical way for heterosexually active women: Both require women's knowledge of their own risk behavior, but the recommended indications also require women's knowledge of their partners' HIV risk or recognition of a potentially asymptomatic sexually transmitted infection. This study examined women's PrEP eligibility according to these 2 different versions of criteria across risk and motivation categories.

Setting/Methods: HIV-negative women (n = 679) recently engaged in care at Connecticut Planned Parenthood centers were surveyed online in 2017. The survey assessed PrEP eligibility by both versions of Centers for Disease Control and Prevention criteria, HIV risk indicators, PrEP motivation indicators, and sociodemographic characteristics.

Results: Participants were mostly non-Hispanic white (33.9%) or black (35.8%) and had low income (<$30,000/year; 58.3%). Overall, 82.3% were eligible for PrEP by guidance summary criteria vs. 1.5% by recommended indications criteria. Women disqualified by recommended indications criteria included those reporting condomless sex with HIV-positive or serostatus-unknown male partners (n = 27, 11.1% eligible); 1 or more recent sexually transmitted infection(s) (n = 53, 3.8% eligible); multiple sex partners (n = 168, 3.0% eligible); intended PrEP use (n = 211, 2.8% eligible); and high self-perceived risk (n = 5, 0.0% eligible).

Conclusion: Current guidelines disqualify many women who could benefit from PrEP and may lead to discrepant assessments of eligibility. Guideline reform is needed to improve clarity and increase women's PrEP access and consequent HIV protection.

aDepartment of Psychology, George Washington University, Washington, DC;

bCenter for Interdisciplinary Research on AIDS, Yale University, New Haven, CT;

cMiriam Hospital, Providence, RI;

dWarren Alpert Medical School, Brown University, Providence, RI;

ePerelman School of Medicine, University of Pennsylvania, Philadelphia, PA;

fDepartment of Psychology, Yale University, New Haven, CT;

gDepartment of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT;

hDivision of General Pediatrics, Boston Medical Center, Boston, MA;

iDivision of General Internal Medicine, Montefiore Medical Center, New York, NY;

jDepartment of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC; and

kPlanned Parenthood of Southern New England, New Haven, CT.

Correspondence to: Sarah K. Calabrese, PhD, Department of Psychology, George Washington University, 2125 G Street NW, Washington, DC 20052 (e-mail:

Supported by the Center for Interdisciplinary Research on AIDS (CIRA) Pilot Projects in HIV Program at Yale University. CIRA is funded by the National Institute of Mental Health (NIMH) through Award Number P30-MH062294. Effort was supported by the NIMH through Award Numbers K01-MH103080 (S.K.C.), F31-MH113508 (T.C.W.), and T32-MH02003 (T.T.). Additional support for T.C.W. was provided by the NIMH through the Brown Initiative in HIV and AIDS Clinical Research for Minority Communities (R25-MH083620). Additional support for T.T. was provided by the National Institute on Drug Abuse (NIDA) through the HIV/AIDS, Substance Abuse, and Trauma Training Program at the University of California, Los Angeles (R25-DA035692). The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH, NIDA, National Institutes of Health (NIH), or Planned Parenthood Federation of America, Inc.

Presented in part at the 13th International Conference on HIV Treatment and Prevention Adherence; June 8, 2018; Miami, FL.

S.K.C. has received compensation for developing and delivering medical education related to PrEP. The remaining authors have no conflicts of interest to disclose.

S.K.C. and T.C.W are the cofirst authors.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received November 25, 2018

Accepted February 27, 2019

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