Ob/gyns can channel their contraceptive counseling skills into patient conversations about screening and preexposure prophylaxis (PrEP) for HIV, according to a new Committee Statement from the American College of Obstetricians & Gynecologists (ACOG).

“PrEP is an excellent tool for reducing HIV infection, but women and people capable of pregnancy experience many barriers to its use, including limited knowledge by their reproductive healthcare providers,” said lead author Jessika Ralph, MD, MS, FACOG, an associate professor at the University of Minnesota in Minneapolis. “I hope this document provides clinicians with an easy-to-use resource to prescribe PrEP for their patients.”

The statement, published in Obstetrics & Gynecology, was developed to guide ob/gyns and other healthcare professionals in counseling patients about HIV screening and prevention during routine visits, in support of the Ending the HIV Epidemic initiative to reduce new HIV diagnoses in the US by 90% by 2030. The initiative, established by the US Department of Health and Human Services in 2019, emphasizes early diagnosis and rapid treatment, as well as PrEP and prompt response to outbreaks.

The committee’s recommendations for HIV reduction include conducting “comprehensive, inclusive, and nonjudgmental” sexual histories during routine wellness visits for individuals of all ages, regardless of marital status or perceived risk, and recommending at least one lifetime HIV test for all individuals aged 15-65 years using an opt-out approach. Individuals with ongoing risk factors should be offered more frequent testing, and pregnant patients should be screened at least once during pregnancy.

The statement includes the CDC’s Five P’s Approach for Health Care Professionals Obtaining Sexual Histories, which focuses on partners, practices, protection from sexually transmitted infections (STIs), past history of STIs, and pregnancy intentions.

Proactive Prevention

The new statement advises healthcare professionals to initiate discussions of HIV prevention and PrEP during routine visits with all sexually active adults and adolescents at increased risk for HIV. Given that ob/gyns provide approximately half of women’s preventive health visits each year, conversations about reproductive health and prevention of STIs can be adapted to include shared decision-making about HIV screening, prevention, and PrEP, according to the statement.

Risk factors for HIV include a past year history of an STI or a 6-month history of gonorrhea or syphilis, inconsistent condom use during vaginal or anal intercourse, a known HIV-positive partner, multiple sexual partners of unknown HIV status, use of injection drugs, history of transactional sex, and residence in a correctional facility.

Local HIV epidemiology can guide healthcare providers in counseling patients, but PrEP should be prescribed to anyone who requests it, and to anyone at an increased risk of acquiring HIV, according to the statement.

Hesitation in discussing risk factors for HIV remains a barrier, as does insurance coverage and medication cost, Ralph noted. The National Alliance of State and Territorial AIDS Directors has a list of PrEP assistance programs to help cover costs for patients, as well as billing and coding resources for clinicians, she said.

Expanding Care

“The updated Committee Statement reflects both the continued public health burden of HIV and the rapid evolution of HIV prevention strategies, particularly the expanding role of preexposure prophylaxis,” said Aleksandr M. Fuks, MD, FACOG, p rofessor and chair in the d epartment of ob/gyn at the Quillen College of Medicine, East Tennessee State University in Johnson City.

“By updating the prior 2014 guidance, ACOG incorporates current epidemiologic data, newer PrEP formulations including long-acting injectable agents, and emphasizes a shared decision-making model, equitable access, and initiative to reduce disparities in HIV prevention,” said Fuks, who was not involved in developing the statement.

However, many clinicians are still uncomfortable discussing sexual health or may underestimate a patient’s risk for HIV exposure, said Fuks. “Time constraints during office visits, limited familiarity with PrEP prescribing, reimbursement issues, and stigma surrounding HIV continue to impede implementation,” he added. “The statement also highlights significant disparities in PrEP uptake among women, Black patients, adolescents, and transgender individuals, driven by structural barriers including poverty, racial disparities, healthcare access, and medical mistrust,” he said.

Overcoming these challenges requires a systems-based approach, with HIV prevention being a routine component of well-woman care rather than something reserved for patients perceived to be at high risk for exposure, said Fuks.

Incorporating standardized sexual history tools, such as the CDC’s Five P’s, into the electronic health record can facilitate HIV discussions, said Fuks. Provider education, clinical decision-support tools, multidisciplinary collaboration with infectious diseases specialists and pharmacists, and improved insurance coverage for PrEP can further enhance implementation, he said. “Community outreach and culturally sensitive counseling are essential to building trust and improving uptake among underserved populations,” he emphasized.

Continued evaluation of emerging prevention technologies, including twice-yearly injectable therapies, vaginal rings, implants, and dual prevention products combining contraception with HIV prevention, will be important. Comparative effectiveness studies, patient preferences, cost-effectiveness analyses, and long-term safety data will help further refine individualized HIV prevention strategies, Fuks noted.

Disclosure information for the committee members is available in the full statement publication. Fuks had no financial conflicts to disclose.