Getting Comfortable with PrEP: A Provider’s Perspective
PrEP, short for pre-exposure prophylaxis, is a relatively new HIV prevention strategy in which an HIV-negative person takes a daily pill to reduce the risk for acquiring HIV. The sole drug currently approved for PrEP is Truvada—a combination antiretroviral that is widely prescribed for HIV treatment.
Results from extensive clinical trials show that PrEP works when people take it; in fact, an analysis of blood drug levels among participants in the global iPrEx trial puts protection at 99% or more when individuals take PrEP daily as prescribed.
That said, PrEP isn’t perfect; it does not prevent other sexually transmitted infections, for example, and not everyone is willing or able to take a pill every day. But for people at high risk for HIV infection who do want to use PrEP, shouldn’t they be supported in their HIV prevention efforts?
Longtime HIV doc Joel Gallant, MD, MPH, says yes. “Let’s agree that abstinence is the only prevention method that’s 100% effective, but that abstinence is unacceptable to most human beings,” he writes on his “Ask Dr. Joel” blog. “Everything else—condoms and PrEP included—are imperfect but effective ways to prevent HIV infection. We should embrace the strategy of harm reduction, and not deny access to prevention tools that have been clearly shown to work.”
In this Q&A, Dr. Gallant offers his perspective on some health care providers’ reluctance to prescribe PrEP, the difference between managing patients on antiretroviral PrEP and individuals taking the same meds for HIV treatment, and how non-HIV-specialists can get comfortable prescribing PrEP and working with those who stand to benefit from it the most.
At a recent think tank on gay men’s sexual health, we heard that some medical providers are hesitant to prescribe PrEP because they are unfamiliar with it, or because they see antiretroviral drugs as the purview of HIV specialists. Have you encountered this kind of reluctance among providers?
Dr. Joel Gallant: One of the obstacles to the widespread use of PrEP is that HIV experts, who are familiar with antiretroviral agents and might be comfortable prescribing PrEP, often don’t see HIV-negative patients, while primary care providers who don’t prescribe antiretrovirals for treatment may be reluctant to prescribe them for prevention.
Clinicians who care for both HIV-positive and HIV-negative patients, such as those who work with the gay community, should be ideal candidates for providing PrEP, but even within that group we still have work to do. For example, I saw a gay man who was at high risk for HIV infection but had been refused PrEP at a clinic serving the gay community because he wasn’t in a monogamous relationship with an HIV-positive partner. This was a serious misunderstanding of both the indications for PrEP and risk factors for HIV transmission.
Paternalistic or moralistic thinking on the part of clinicians can be another obstacle to the appropriate use of PrEP. I’ve heard of patients being denied PrEP because they admitted they didn’t intend to use condoms consistently. Of course we should talk about condom use when we prescribe PrEP, but if everyone wore condoms, there would be no need for PrEP.
On a more positive note, patients have been referred to me for PrEP by primary providers who were later willing to take over the monitoring and prescribing of PrEP once they saw how easy it was.
How has your own experience prescribing PrEP compared with managing chronic HIV infection with antiretrovirals?
Dr. Gallant: Prescribing and monitoring PrEP is much easier than managing HIV infection. It’s done in a very “cookbook” approach using straightforward algorithms. In contrast to HIV management, you rarely have to deal with significant drug toxicity, drug interactions, or complex treatment choices.
Also, loss to follow-up is less important with PrEP than with HIV treatment. If an HIV-positive patient stops taking medications or drops out of care, he runs the risk of drug resistance and disease progression. On the other hand, in clinical trials of PrEP, participants tended to sort themselves out into either “takers” or “non-takers” right away.
Non-adherence can mess up the results of a clinical trial. In the “real world,” there will be people who come in for that first three-month prescription but stop taking it and never come back. They’re obviously at risk for HIV infection, but no more than they would have been otherwise if they weren’t using condoms, and they cease to incur the cost of ongoing PrEP.
What can HIV docs do to encourage other providers to feel comfortable prescribing PrEP and working with PrEP users?
Dr. Gallant: In the cases I mentioned, I tried to educate the referring primary care providers through my own patient visit notes, outlining the expectations for monitoring of drug toxicity and screening for HIV infection and other sexually transmitted infections. I told these patients that their providers could easily take over the process if they were willing, and gave them information about web-based tools to share with their doctors. That worked well in several cases.
Of course, primary care providers who are willing to refer their high-risk patients to an HIV expert for PrEP may be a small and more trainable subset of clinicians. The clinicians who are harder to reach are the ones who don’t know about PrEP, don’t discuss sex or risk reduction with their patients, or who believe that the only morally acceptable approaches to HIV prevention are condoms and abstinence. Reaching that group will require a combination of continuing medical education and advocacy by informed patients.
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Resources for Providers
New to PrEP, or looking to better understand how to work with patients who are interested in PrEP or already using this HIV prevention tool? These resources are for you.
Fact Sheet: PrEP and PEP: Start here for key terms and concepts to help you understand PrEP and PEP, and the differences between these two ways of reducing risk for HIV infection.
Information for Health Care Providers: Truvada for a PrEP Indication: Gilead Science’s provider education page includes a checklist on prescribing PrEP, Truvada safety and efficacy data, a training guide for health care providers, a printable medication assistance application form for eligible patients, and other resources.
PrEP: A New Tool for HIV Prevention [PDF]: A helpful table in this fact sheet covers how to prescribe and monitor PrEP. (Note that this fact sheet from the Centers for Disease Control and Prevention [CDC] does not include the latest data on PrEP for people who inject drugs; see below to learn more about PrEP research in this population.)
Video: Three PrEP Myths Busted: Get the basics around PrEP science and see three big myths about PrEP dispelled in this smart and accessible whiteboard video.
CROI 2013: iPrEx Update—A Q&A with Dr. Robert Grant: Get this PrEP researcher and MD’s take on periodic PrEP use, starting and stopping safely, and why the term “condomless sex” is replacing “unprotected sex” in HIV prevention dialogs.
Taking Routine Histories of Sexual Health: This comprehensive “toolkit” from the Fenway Institute and the National Association of Community Health Centers aims to help clinicians integrate sexual health into their patient visits and includes recommended screening questions and risk assessments; information on coding and billing; guidance for working with transgender individuals and gay and bi men, who are at increased risk for HIV and other sexually transmitted infections; and a PowerPoint presentation designed for training clinic staff.
PrEPfacts.org: Understand key PrEP research (and share it with your patients) via this comprehensive, user-friendly PrEP education site from San Francisco AIDS Foundation.
BETA’s “virtual library” of PrEP resources: Use this ever-growing compilation of articles, videos, Q&As, and other resources to keep abreast of developments in PrEP research and gain insight with perspectives from PrEP users, researchers, and other experts in the field.
Reilly O’Neal is a freelance writer and former editor of BETA.