About 60 percent of U.S. deaths are caused by heart disease and cancer. If you were at risk for either, would you take a pill to lower your chances of getting sick? Would you be embarrassed to ask your provider about it? Would your provider make it harder to get the pill by requiring you go to a specialist, as opposed to prescribing it himself or herself?
Well, we have an HIV-prevention pill, yet only a fraction of people with ongoing risk of exposure to the virus have been prescribed it. The pill isn’t new. In fact, it has been approved by the Food and Drug Administration for more than six years.
Called Truvada, the medication is approved as a pre-exposure prophylaxis, also known as PrEP, among persons at risk for HIV infection. To be eligible for PrEP, one must be HIV-negative and at risk of acquiring HIV through sex or other behaviors like injecting drugs. The initial approval was only for adults; however, in 2018, the FDA approved Truvada for at-risk adolescents who weigh at least 77 pounds. Last year, the federal agency also approved a generic version of Truvada, but it is not expected to be released for another year or two.
According to the Centers for Disease Control and Prevention, about half of gay and bisexual black men and a quarter of gay and bisexual Latinos are at risk of contracting HIV in their lifetimes. In all, an estimated 1.2 million people could benefit from Truvada, yet only 90,000 PrEP prescriptions were filled in pharmacies in 2015, according to the CDC.
So, where’s the disconnect?
Among primary care providers, the barriers include limited knowledge about PrEP, discomfort talking about sexual health, concerns about insurance coverage and reimbursement, concerns about the efficacy of Truvada, long-term safety of PrEP, fear of judgment from their patients for assuming they may engage in high-risk behaviors, and the possibility that going on PrEP will encourage unprotected sex.
Gay and bisexual men and others who engage in risky behaviors cite stigma and discrimination from their providers, lack of knowledge about how PrEP works, fear of being judged by potential sex partners, and the burdens of quarterly provider checkups and simply remembering to take a pill every day.
Removing these barriers will require significant changes, including in our health care systems. Below are ways to address some of these barriers.
- Update graduate medical education curricula to include more sexual health medicine and prevention.
- Offer continuing medical education credits for PrEP.
- Offer widespread clinical consultation services like hotlines and referral services to answer provider questions.
- Increase PrEP detailers, a marketing model used by pharmaceutical companies to educate clinicians about a product.
- Advocate for age-appropriate, medically accurate, school-based sex education.
- Disseminate PrEP-related social marketing campaigns in print and on social media.
- Offer low cost or free sexual health screenings and services in stand-alone clinics or in one-stop-shop models where sexual health is located with primary care, dentistry, etc.
- Increase individual and group counseling services to address PrEP-related stigma and shaming.
PrEP is a safe and effective way to prevent HIV — if we can remove the barriers to its widespread use. We have a lot of work to do.
Anthony J. Santella is an associate professor of public health at Hofstra University and chair of the Nassau-Suffolk Ryan White HIV Planning Council.