title: Effectiveness and safety of oral HIV preexposure prophylaxis for all populations.
abstract: Preexposure prophylaxis (PrEP) offers a promising new approach to HIV prevention. This systematic review and meta-analysis evaluated the evidence for use of oral PrEP containing tenofovir disoproxil fumarate as an additional HIV prevention strategy in populations at substantial risk for HIV based on HIV acquisition, adverse events, drug resistance, sexual behavior, and reproductive health outcomes.
  
  
  
  Rigorous systematic review and meta-analysis.
  
  
  
  A comprehensive search strategy reviewed three electronic databases and conference abstracts through April 2015. Pooled effect estimates were calculated using random-effects meta-analysis.
  
  
  
  Eighteen studies were included, comprising data from 39 articles and six conference abstracts. Across populations and PrEP regimens, PrEP significantly reduced the risk of HIV acquisition compared with placebo. Trials with PrEP use more than 70% demonstrated the highest PrEP effectiveness (risk ratio = 0.30, 95% confidence interval: 0.21-0.45, P < 0.001) compared with placebo. Trials with low PrEP use did not show a significantly protective effect. Adverse events were similar between PrEP and placebo groups. More cases of drug-resistant HIV infection were found among PrEP users who initiated PrEP while acutely HIV-infected, but incidence of acquiring drug-resistant HIV during PrEP use was low. Studies consistently found no association between PrEP use and changes in sexual risk behavior. PrEP was not associated with increased pregnancy-related adverse events or hormonal contraception effectiveness.
  
  
  
  PrEP is protective against HIV infection across populations, presents few significant safety risks, and there is no evidence of behavioral risk compensation. The effective and cost-effective use of PrEP will require development of best practices for fostering uptake and adherence among people at substantial HIV risk.
authors.affiliation: aJohns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA bHIV Department, World Health Organization, Geneva, Switzerland cMedical University of South Carolina, Charleston, South Carolina, USA dHIV Department, World Health Organization, Switzerland; Gladstone Institutes and the University of California; San Francisco AIDS Foundation, San Francisco, California, USA.
authors.forename: Virginia A
authors.initials: VA
authors.lastname: Fonner
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Dalglish
authors.forename: Caitlin E
authors.initials: CE
authors.lastname: Kennedy
authors.forename: Rachel
authors.initials: R
authors.lastname: Baggaley
authors.forename: Kevin R
authors.initials: KR
authors.lastname: O'Reilly
authors.forename: Florence M
authors.initials: FM
authors.lastname: Koechlin
authors.forename: Michelle
authors.initials: M
authors.lastname: Rodolph
authors.forename: Ioannis
authors.initials: I
authors.lastname: Hodges-Mameletzis
authors.forename: Robert M
authors.initials: RM
authors.lastname: Grant
mesh_terms: D000284:Administration, Oral; D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000009:adverse effects; D018890:Chemoprevention / Q000009:adverse effects* / Q000379:methods*; D005260:Female; D015658:HIV Infections / Q000517:prevention & control*; D006801:Humans; D008297:Male; D010919:Placebos / Q000008:administration & dosage; D065129:Pre-Exposure Prophylaxis / Q000379:methods*; D000068698:Tenofovir / Q000008:administration & dosage / Q000009:adverse effects; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents; D010919:Placebos; D000068698:Tenofovir