COMMENTARY

PrEP: Simple and Effective Yet Underused

Jonathan Mermin, MD, MPH

Disclosures

November 30, 2015

Editorial Collaboration

Medscape &

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Hello. I'm Dr Jonathan Mermin, Director of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at the Centers for Disease Control and Prevention (CDC). I'm pleased to speak with you today about pre-exposure prophylaxis (PrEP), an important way for clinicians to protect their patients from becoming infected with HIV.

PrEP involves an HIV-negative person taking a pill containing tenofovir and emtricitabine. PrEP is taken daily and reduces sexual acquisition of HIV by more than 90% when taken correctly. Clinicians are key to increasing awareness of PrEP, and you can discuss HIV risk with all patients to better identify those who would benefit.

Every year, about 45,000 people in the United States are diagnosed with HIV. PrEP complements other tools to prevent HIV, such as condom use, HIV testing, and early diagnosis and treatment of HIV infection.

Any prescribing healthcare provider can deliver PrEP care. You have the power to protect your patients from HIV by assessing their risk from sex and drug use behaviors and offering PrEP to patients with the recommended indications.

CDC estimates that 1.2 million people in the United States may have indications for PrEP use, and these people fall into three groups[1]:

  • About 1 in 4 HIV-negative sexually active gay and bisexual adult men. This includes men who have multiple sex partners and report any anal sex without a condom or who had a recent sexually transmitted infection, as well as men who have an ongoing sexual relationship with an HIV-positive partner.

  • About 1 in 5 HIV-negative adults who inject drugs. This includes people who share needles or equipment to inject drugs or have recently been in a drug treatment program.

  • About 1 in 200 sexually active, HIV-negative heterosexual adults. This includes adults in an ongoing sexual relationship with HIV-positive partners. It also includes people who have multiple sex partners and who infrequently use condoms during sex with partners known to be at substantial risk for HIV infection. Partners at substantial risk include people who inject drugs and, for women, bisexual men.

Integrating the delivery of PrEP care into your practice involves five key steps:

  • Test all adolescent and adult patients for HIV as recommended by the US Preventive Services Task Force and CDC as a routine part of medical care. Patients who test positive for HIV should be prescribed HIV treatment right away.

  • Discuss HIV risks and prevention methods with all patients. If an HIV-negative patient has indications for PrEP and is interested in taking it, then move on to the next step.

  • Perform the recommended laboratory tests, including tests to exclude acute HIV infection if the symptom history suggests this, and tests for renal function and hepatitis B virus. If the tests show that the patient is still a candidate for PrEP, then move on to the next step.

  • Prescribe PrEP to your patient and counsel them about steps that they can take to make sure that PrEP is taken every day. If payment is an issue, provide assistance as to how they may apply for insurance or other programs.

  • The last step is to schedule appointments every 3 months for follow-up including HIV testing and prescription refills.

Incorporating PrEP into your practice is simple, and it works. Since CDC published the Public Health Service Clinical Practice Guidelines for PrEP in 2014, open-label studies and demonstration projects conducted with gay and bisexual men in the United States achieved high adherence with PrEP.[2,3,4,5,6] And a recent study conducted in New York State suggests that the use of PrEP as a prevention tool can be increased substantially for persons who are Medicaid-insured—if education efforts about PrEP for both clinicians and patients are implemented successfully.[7]

In closing, increasing the use of PrEP by patients could be a major tool in reducing the number of new HIV infections in the United States. But many clinicians who can prescribe PrEP, and many people who can benefit from it, aren't aware of it. Together we can scale up the use of this important HIV prevention tool. Thank you for your time today.

For more information, go to www.cdc.gov/hiv.

Web Resources

CDC Pre-Exposure Prophylaxis (PrEP)

CDC Vital Signs

Jonathan Mermin, MD, MPH, is the director of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP). Prior to his appointment, Dr Mermin served as director of the Division of HIV/AIDS Prevention, NCHHSTP, from 2009 to 2013. Under his leadership, the Division spearheaded a new approach to HIV prevention, called High Impact Prevention, that aligned funding with epidemiology and ensured that program and research activities had the greatest effect on reducing incidence and improving health equity.

A captain in the US Public Health Service Commissioned Corps, Dr Mermin served as director of CDC-Kenya and Department of Health and Human Services Public Health Attaché for the US Embassy from 2006 to 2009, where he oversaw CDC's largest country office, implementing programs and research involving a broad range of infectious diseases, including HIV, malaria, tuberculosis, and emerging infections.

From 1999 to 2006, Dr Mermin was director of CDC-Uganda, where he oversaw CDC's HIV prevention and care programs, including implementation of the first antiretroviral treatment program funded by CDC outside of the United States and the development of a basic care package that was incorporated into PEPFAR and World Health Organization guidelines.

Dr Mermin began his career at CDC in 1995 as an Epidemic Intelligence Service officer with the Foodborne and Diarrheal Diseases branch. He completed an internal medicine residency at San Francisco General Hospital and a preventive medicine residency at CDC and the California Department of Health Services. He is a graduate of Harvard College and Stanford University School of Medicine and received his MPH from Emory University. He has coauthored more than 150 scientific articles. He currently serves as an adjunct professor at Emory University School of Public Health.

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