PrEP (pre-exposure prophylaxis) effectively prevents HIV transmission. In 2012, the FDA approved daily tenofovir/emtricitabine (Truvada) for use as PrEP based on two large efficacy studies. A third study in 2015 found that men who have sex with men (MSM) taking PrEP "on demand" reduced HIV transmission risk by an average of 86%.
Despite these overwhelming results, uptake has been slow. We asked providers and community leaders what they thought needed to happen for PrEP to reach everybody who needs it.
Interviews were conducted and photos were taken by Terri Wilder and Warren Tong.
There has to be intentional direction towards engaging not only the physicians and the at-risk communities but also everyone in between to make sure people are aware, not only that PrEP exists, but how to access it and that it's fully affordable. I live in a state where the governor has signed a law that has not only mandated that people receive information about PrEP upon receiving an HIV-negative test; he's also signed a bill that makes sure that every resident has access to it -- meaning, whether or not you're on Medi-Cal, you're uninsured, you're on an Obamacare equivalent or you have your regular insurance. All fund streams actually go through.
I think the number one thing -- and probably it's the most difficult, but it's the most obvious -- is that countries need to include PrEP as prevention in their national policies. Until that happens, like it has in the U.S., then uptake is always going to be hampered -- because of the cost of drugs, because of the way the drugs are accessed. Even in the U.S., uptake is still only really about half of the way it could be, but there's still 80,000 people taking PrEP. That has to be the number-one thing: the policies have to change. For me, it has to start at the national level.
Governments have to approve PrEP. Of course, approval doesn't mean access, as we've seen in Peru. And approval here [in the U.S.] didn't mean instant access. But, without that, physicians who may be interested, some of them aren't willing to step outside guidelines. They want official approval. We have eight countries that have officially approved. Not very good access exists in all of those.
In 29 countries -- from global north, global south, three different languages -- people are going to incredible lengths to try to get PrEP and are doing it on their own. It's insane, from a public health perspective.
We have to reorient ourselves around who is eligible for PrEP and who really needs to be considered for PrEP therapy. In particular, women have been pretty much left out of the equation. The eligibility for women is about the same as the eligibility for men who have sex with men. We have to really recalibrate whom we're going after and why, as far as PrEP implementation is concerned. ... No one realizes that women are supposed to be getting it -- including the people that are putting the resources out there. We've got to make sure that everyone's clear that women need to be at the forefront of PrEP uptake, as well.
We need a marketing campaign -- a big, flashy, "here's what the hell this thing is." Because, as much as we talk about it in our HIV bubble, it is not reaching well outside the bubble.
It's important to adopt both individual and structural approaches. Structural approaches are important because you can only give people day-to-day coping strategies for so long. ... We need to, for instance, ensure that every person has access to fact-based, sex-positive, judgment-free, sexual health education. I think that is important and vital.
I think we also need to look at programs that exist for HIV treatment that could also be retooled for HIV prevention -- like, for example, the Ryan White CARE Program ... that can be utilized to help gear resources toward people and communities where PrEP has not penetrated.
One of the very first barriers that people encounter is lack of awareness. A lot of people who could really benefit from PrEP have no idea that it even exists. ... That even includes a lot of gay men, who we think about as having the greatest level of awareness -- which they do. But I've just recently done focus groups with gay men across the country, and a lot of them heard about PrEP for the first time when they came to the focus group. ...
I think a lot of other groups that could benefit have even lower levels of access -- women at risk, people who use drugs, people in indigenous communities, sex workers.
It needs to be less costly, and we need a much broader educational campaign. Not everybody knows about it, yet. So, until everybody knows about it, it can't be accessible. Once everybody knows about it, we need to make sure that we have programs in place, that people can access it and that there are no financial and regulatory and legal barriers to them getting it.
It means that we have to make all the efforts to make it available for anyone that needs it without them to have to pay for it. That's a crucial question, because not everyone can afford it. Targeting the right populations that are most at risk: big cities, I would say; sex workers; and gay people. That's what I would say.