Integrating HIV Preexposure Prophylaxis (PrEP) Into Routine Preventive Health Care to Avoid Exacerbating Disparities

Sarah K. Calabrese, PhD; Douglas S. Krakower, MD; Kenneth H. Mayer, MD

Disclosures

Am J Public Health. 2017;107(12):1883-1889. 

In This Article

Abstract and Introduction

Abstract

More than 3 decades since its emergence in the United States, HIV continues to spread and disproportionately affect socially marginalized groups.

Preexposure prophylaxis (PrEP), a highly effective prevention strategy federally approved since 2012, could fundamentally alter the course of the epidemic. However, PrEP's potential has not been fully realized, in part because health care providers have been slow to adopt PrEP in clinical practice and have been selective in their discussion of PrEP with patients. This nonstandardized approach has constrained PrEP access. PrEP access has not only been inadequate but also inequitable, with several groups in high need showing lower rates of uptake than do their socially privileged counterparts.

Recognizing these early warning signs that current approaches to PrEP implementation could exacerbate existing HIV disparities, we call on health professionals to integrate PrEP into routine preventive health care for adult patients—particularly in primary care, reproductive health, and behavioral health settings. Drawing on the empirical literature, we present 4 arguments for why doing so would improve access and access equity, and we conclude that the benefits clearly outweigh the challenges.

The year 2012 was a landmark year in the history of HIV prevention. The US Food and Drug Administration approved the first HIV preexposure prophylactic agent for prescription: tenofovir disoproxil fumarate with emtricitabine (Truvada). This daily oral antiretroviral medication is effective in protecting HIV-negative adults from acquiring HIV[1] and is indicated for those at risk because of sexual behavior, injection practices, or both.[2]

Preexposure prophylaxis (PrEP) is an important addition to the menu of prevention options offered to patients in health care settings because traditional prevention methods, such as condoms, have only partially addressed the HIV epidemic. HIV continues to spread, with transmission accelerated among certain groups in particular (e.g., Black men who have sex with men [MSM].[3,4] Whether used alone or combined with other prevention methods, PrEP confers numerous benefits and few known risks. Many of the benefits are unique to PrEP and cannot be obtained via other forms of protection, including its potential for covert use without a partner's knowledge, allowance of HIV-protected natural conception, dual protection against both sexual and injection risks, and dissociation from the timing of an exposure event (thus avoiding decision-making in the "heat of the moment" or when judgment is impaired by concurrent substance use).

Despite the immense promise of PrEP and the unique advantages it affords, many health care providers, including those aware of this recent prevention innovation, have not discussed PrEP with their patients or prescribed it.[5,6] Providers have reported several barriers to prescribing PrEP, such as difficulty determining eligibility and time demands associated with provision and follow-up monitoring,[5,7] but preliminary evidence suggests that these challenges may be overestimated and are often manageable in practice.[8] The slow adoption of PrEP in clinical practices has contributed to the gap between the number of people who have taken PrEP in the United States, which is around 100 000,[9] and the number at significant risk for HIV and for whom PrEP is indicated, which exceeds 1.2 million.[10] Furthermore, the nonstandardized approaches to PrEP provision in clinical practices that have adopted PrEP may limit PrEP education and access for some individuals more than others,[11] thus promoting inequities.

We argue that PrEP should be discussed with all adult patients as part of routine preventive health care—particularly in primary care, reproductive health, and behavioral health settings—and made available to those who elect to use it unless medically contraindicated. Providing all patients with a basic overview of PrEP ensures that all are aware of its existence, and further education and provision can be tailored to patients' individual preferences and circumstances. Routinizing the discussion and offering of PrEP would improve access to PrEP, thereby curbing HIV spread, and improve access equity for Black MSM and other socially marginalized groups disproportionately affected by HIV, which would help avoid exacerbating existing HIV disparities through PrEP-related clinical practices.

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