PrEP uptake poised to grow as physicians gain insight, stigmas fade
Pre-exposure prophylaxis, or PrEP, has been approved for HIV prevention in the United States since 2012, and guidelines for its use have been in place since 2014.
Despite CDC estimates that say PrEP can reduce the risk for acquiring HIV through sex by more than 90% and through injection drug use by more than 70%, only a fraction of the people who meet the indication for PrEP are taking Truvada (emtricitabine/tenofovir disoproxil fumarate, Gilead Sciences; FTC/TDF).
But experts say some barriers that have led to a slow initial uptake in PrEP are beginning to crumble as more doctors learn about FTC/TDF and stigmas surrounding its use begin to fade.
“We’re not at the point yet that I think PrEP is having a big public health impact in most places, but I think we could see that happen in the future with greater uptake,” Joel Gallant, MD, MPH, medical director of specialty services at Southwest Care Center in Santa Fe, New Mexico, and past chair of the HIV Medicine Association, told Infectious Disease News.
An important tool for HIV prevention
FTC/TDF must be taken daily to be effective, according to the CDC. A spokesman for Gilead Sciences told Infectious Disease News that more than 40,000 people are receiving the drug for HIV prevention. That is well below the estimated 1.2 million Americans who meet the indication for taking PrEP.
When taken consistently, FTC/TDF is an important tool in association with other HIV prevention methods, according to Dawn K. Smith, MD, MS, MPH, of the CDC’s Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention.
“We want to make PrEP available to people so that those who aren’t consistently able to use condoms or those who are not yet ready to enter a drug treatment program can still remain HIV-uninfected,” Smith said in an interview.
Clinicians lack PrEP awareness
In December, the CDC announced that one in three primary care physicians (PCPs) and nurses had not heard of PrEP.
“Doctors are definitely not getting the message,” Gallant said. “When they get the message, it’s often from their own patients. Some of them hear that message and want to learn about it, and they end up becoming PrEP providers. Others don’t approve of it or don’t feel competent to prescribe it and are not willing to learn.”
PCPs should not only routinely test their patients for HIV, they should be talking to them to assess their risk for HIV exposure, said Jeanne M. Marrazzo, MD, MPH, director of the division of infectious diseases at the University of Alabama at Birmingham.
“They may not want to talk about it, but just opening that dialogue is a way to make people aware” of PrEP, Marrazzo told Infectious Disease News.
The lack of knowledge among PCPs may lead to what is seemingly the biggest stigma surrounding PrEP.
“Many people are going to HIV clinics to get PrEP,” Gallant said. “There may be a stigma about being seen in a clinic that’s primarily known as an HIV clinic.”
PrEP stigmatized by association with HIV
Indeed, the stigma of being on PrEP mainly comes from being associated with HIV in any way, not from taking the medicine, according to Smith.
“Whether it’s treatment or prevention or risk behaviors,” Smith said, “there’s still a fair amount of stigma in the community about HIV in general as a health issue, and some of that spills over into prevention activities like PrEP.”
As a protocol co-chair on the VOICE trial, which showed a consistent pattern of nonadherence to PrEP among women in three African countries, Marrazzo saw how uptake was negatively affected by FTC/TDF’s association with ART.
“We did not appreciate that uptake would be so poor, particularly by women,” Marrazzo said. “It turned out that most people associated these drugs so much with HIV that they would never really think that they should take them just for the purpose of preventing HIV. So I think that in places where stigma associated with HIV disease is still really palpable, this is a huge concern.”
In the United States, the stigmas associated with taking PrEP are localized in certain social and sexual networks, according to Marrazzo.
“It’s pretty clear that in perhaps very religious communities where family obligations are huge and there is not so much of a visible gay culture, there almost certainly is going to be some stigma associated with accessing PrEP,” she said. “It seems like it reflects what your environment is about, what your support system is and what your expectations are for socially interacting with people around you.”
Smith said certain behaviors that expose individuals to HIV infection can generate stigmas that are tied to how they are perceived by others.
“There are people who don’t approve of, or who have stigmatizing attitudes toward injection drug users or toward people who engage in sexual activities that are different than the kind they engage in,” Smith said.
However, Gallant and Marrazzo agreed that men who have sex with men have begun to reverse the stigma associated with taking PrEP.
“In some parts of the gay community, not only is there very little stigma surrounding PrEP, but being on it is a source of pride,” Gallant said. “I’ve had some men who are fairly low-risk ask me for PrEP because they say nobody will have sex with them if they’re not taking it.”
According to Marrazzo, young gay men at risk for HIV infection have many ways to learn about PrEP.
“So I think awareness in that group is actually pretty good,” she said.
Gallant said the early reaction to PrEP has resembled that of another drug introduced decades ago.
“In the beginning, birth control was stigmatized. It was viewed as a pill that was going to turn women into ‘sluts’ who were going to have lots of unsafe sex and get syphilis,” Gallant said. “We’ve seen similar reactions to PrEP. I’m glad to say that the gay community is turning that stigma around and making HIV prevention with PrEP a positive thing.”
Uptake expected to increase
PrEP uptake should continue to increase as more people become educated about it, according to Gallant and Smith.
“I remember what my first thoughts were when I first heard about PrEP. I thought, ‘Geez, this is a really expensive substitute for a condom. It could create resistance. It could increase STDs,’ ” Gallant said. “Many people have that kind of reaction when they first hear about PrEP. It’s only when they understand the data that those arguments fall apart.”
Smith said it can take years between the time a clinical intervention is proven effective to when it becomes a standard of care.
“There have been analyses that say on average it’s 17 years. We’ve done better than that for HIV in general, but we’re only 2 years from the guidelines being issued for PrEP, so you wouldn’t expect to see instantaneous uptake at high levels,” Smith said. “And now that the CDC and health departments are really putting effort into educating providers and educating the community and providing tools to help move this forward, we expect to see even more acceleration in the next few years.” – by Gerard Gallagher
- CDC. New guidelines recommend daily HIV prevention pill for those at substantial risk. 2014: http://www.cdc.gov/nchhstp/newsroom/2014/prep-guidelines-press-release.html. Accessed April 22, 2016.
- Marrazzo JM, et al. N Engl J Med. 2015;doi:10.1056/NEJMoa1402269.
- Smith DK, et al. MMWR Morb Mortal Wkly Rep. 2015;doi:10.15585/mmwr.mm6446a4.
Disclosures: Marrazzo and Smith report no relevant financial disclosures. Gallant reports receiving consulting and advisory board income and research support from Gilead Sciences.