In the 1980s and 1990s, when HIV/AIDS was stigmatized and poorly understood, the disease was a death sentence. Now, we have available to patients a pre-exposure HIV prophylaxis, known as PrEP, that can prevent HIV transmission, potentially opening the door to immense changes in patients’ lives as well as improved public health outcomes. As part of my public health project, I had the opportunity to survey primary care providers in every county in Vermont to better understand perceived barriers to prescribing PrEP. We completed this work in collaboration with Vermont Cares, Vermont’s largest and longest-serving HIV/AIDS organization.
Despite being well versed on the statistics and studies of PrEP, many providers remain unwilling to prescribe PrEP based on personal concerns of side effects, resistance and risky behavior. To gain a deeper insight of the impact PrEP can have on a person’s life we spoke to a community member who takes PrEP . “To say PrEP was significant or life-changing is an understatement” he began. “For the first time in my life, HIV infection is entirely in my control. I don’t have to rely on others to tell me what they know or what they don’t know.” For me, his words addressed the two goals I hope to achieve by practicing medicine: prevention and patient-empowerment. Our community member taught me that PrEP is more than just a preventative measure; PrEP lifts the stigma off HIV positive individuals, and for the first time they can enjoy a relationship with another person and not have their sero-status divide them. Imagine how meaningful that is if you had experienced the devastation and stigmatization of HIV/AIDs in the 1980’s and 90’s.
PrEP, a daily combination pill of Emtricitabine/ Tenofovir (trade name Truvada), was approved by the FDA in 2012 after multiple studies demonstrated the efficacy and safety of the drug to prevent HIV transmission (it has been shown to decrease the HIV risk by 92 percent). The CDC has recognized 1.2 million people who would benefit from PrEP, but to date only a small percentage of those folks are taking it. Finding willing providers to prescribe PrEP has been a major barrier for patients.
Our survey respondents cited two common barriers: cost to the patient and training for providers. Fortunately, these barriers are modifiable and the CDC has practice guidelines and many online training modules are available as well as an academic detailed summary of PrEP specifically for Vermont primary care providers that was produced by fellow medical students Michael Ohkura (class of 2018) and Nicholas Bonenfant (class of 2017). Insurance is covering PrEP, and there are organizations like Vermont Cares who are linking patients with programs to help cover high deductibles such as the Gilead co-pay Assistance Program.
Any health care professional who can prescribe medications can prescribe PrEP, and certainly any health care provider that cares for their patient’s sexual health should be keeping PrEP in their toolbox and on the table for discussion. We need to take the conversation of HIV prevention away from the HIV positive care arena because PrEP is for HIV negative people. Individuals who would benefit most from PrEP are men who have sex with men, IV drug users, heterosexuals who have unprotected sex with partners of unknown HIV status, sex workers and any individual in a serodiscordant relationship.
“Discussing the most intimate details of one’s sex life can be difficult for the patient and the provider and it takes practice,” our community member said. Vermont Cares offers role-plays and support to patients seeking PrEP to prevent a negative medical interaction, which can result in individuals not wanting to seek health care.
With the ability to offer patients a prevention strategy such as PrEP, providers are able to provide care for their patient’s sexual health and identify not only “high risk individuals” but as Michael and Nicholas highlight, “high risk moments” in a person’s life, such as leaving home, becoming an adult, coming out as a man who has sex with men, immigrating to a new city, ending a relationship and so on. As providers we need to learn the art of leading a conversation about sexual health and include questions such as “are you in an open relationship” because if we don’t ask the questions, we won’t get the answers and we won’t be providing preventative measures or empowering our patients.
Part of our work has been to share the results of our survey with fellow public health professionals and health care providers. Classmate Maggie Graham and I recently presented at the Bridging the Divide Conference, a conference about primary care and public health, with Adessa Yeager, a medical case manager at Vermont Cares. We hope to continue to education and inform providers about PrEP, as awareness is a key first step to improving care for patients at risk for HIV/AIDS.