Eligibility for Pre-exposure Prophylaxis According to Different Guidelines in a Cohort of HIV-Negative Men Who Have Sex with Men in Lisbon, Portugal

Abstract

Objectives. Defining eligibility for preexposure prophylaxis (PrEP) is key to measuring the degree of PrEP implementation. While the clinical exclusion criteria are identical across different guidelines, definitions of substantial HIV risk are not. In this study, we aimed to estimate the proportion of men who have sex with men (MSM) being tested at a community-based voluntary human immunodeficiency virus (HIV) counseling and testing center in Lisbon that would be eligible for PrEP according to guidelines from the World Health Organization (WHO), the US Public Health Service and Centers for Disease Control and Prevention (US-CDC), the European AIDS Clinical Society (EACS), and the Portuguese National Health Service (PNHS). Methods. We used baseline data from 3392 HIV-negative MSM with valid information on eligibility for PrEP enrolled in the Portuguese Lisbon Cohort of MSM—an observational study designed as an open prospective, noninterval cohort—between March 2014 and March 2018. Results. At baseline, the proportion of MSM eligible for PrEP was 67.7% according to the US-CDC, 60.6% according to the PNHS guidelines, 58.9% according to the WHO, and 46.5% according to the EACS guidelines. The most frequently met criteria were those related to condomless anal intercourse. Conclusions. In conclusion, in the same population, the proportion of men eligible for PrEP differed by guideline, ranging from 46.5% to 67.7%, though if they all seem to include the same well-known predictors of HIV seroconversion. Policy implications. These results show that both the allocation of resources and the approaches to individual risk prediction are highly dependent on the chosen guideline. Moving the focus from assessing risk to assessing whether PrEP is a suitable option for a given individual in a given moment of his life might help to overcome guidelines limitations and create more equitable access.