The Challenges of Implementing HIV Preexposure Prophylaxis

Can PrEP be done on a broader scale?

Paul E. Sax, MD


June 18, 2014

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Hello. This is Dr. Paul Sax, from Brigham and Women's Hospital and Harvard Medical School in Cambridge, Massachusetts.

You are probably aware that last month, the Centers for Disease Control and Prevention (CDC) issued a much broader recommendation[1] for the use of preexposure prophylaxis, or PrEP. They did this because the incidence of HIV infection has remained stubbornly high, at about 50,000 new cases a year, even though we have the means to prevent it through the regular use of condoms, treatment of people who have HIV infection, and so on. But unfortunately, the incidence has not gone down.

One additional potential tool is the use of PrEP. The CDC has recommended it now for people who are at high risk of acquiring HIV, specifically men who have sex with men and are in serodiscordant relationships; men who have sex with men who have recently been diagnosed with a bacterial sexually transmitted infection (STI); and those who do not regularly use condoms. The CDC also recommends PrEP for heterosexuals with the same characteristics (in serodiscordant relationships, have a newly diagnosed STI), and if they are located in a high-prevalence area and do not regularly use condoms. They furthermore recommend it for injection-drug users who are sharing needles, and also for some other characteristics.

This is the recommendation. But how will we implement it? It will not be easy, and I believe it will be challenging for 3 reasons.

Three Challenges

First, those who are at highest risk of acquiring HIV are often those who are not engaged in any kind of regular medical care. I am thinking in particular of perhaps the highest-incidence group, which in the United States is younger men who have sex with men -- in particular, African-American men who have sex with men.

Second, this task of identifying high-risk individuals will not fall to infectious disease or HIV specialists, but predominantly to primary care providers. This discussion is not always easy for anyone to have with a patient, but it may be especially challenging for primary care physicians (PCPs).

Third, the recommended therapy for PrEP is tenofovir/emtricitabine, which is not something that PCPs typically prescribe. It is not difficult to prescribe; it's just 1 pill a day. But this is not a medication that most PCPs are familiar with.

So, can PrEP be accomplished on a broader scale? I think it can. But I also think it will be a big challenge. Thank you very much.


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