It has been six years since the World Health Organization (WHO) recommended pre-exposure prophylaxis (PrEP) for serodiscordant heterosexual couples -- a recommendation based on a mountain of evidence that PrEP nearly zeros the risk of transmitting HIV, even among couples that have condomless sex.
Despite the WHO's recommendation, very few people in low- and middle-income countries have access to the once-daily HIV prevention pill, and most are not even aware of its existence. A poster presented by Jodian Pinkney, M.D., of Palmetto Health and University of South Carolina, at the annual IDWeek conference in San Francisco illustrated the lag between WHO's recommendations and PrEP uptake in an urban setting in Jamaica.
According to Pinkney, who is currently completing her infectious disease fellowship at the University of South Carolina, attitudes and awareness of PrEP have not previously been studied in Jamaica.
In 2017, while working in Jamaica, Pinkney and her colleagues evaluated 60 people living with HIV who were regularly receiving care at a clinic in the capital city, Kingston. Their average age was around 40 years old, and about half were cisgender men and women. Fifty-seven of those surveyed said they were in a relationship.
Of those in a relationship, 65% said they were in a serodiscordant relationship, and these responses were split evenly between men and women. Of the people who said their partner was HIV negative, 67% said they had disclosed their HIV status to that partner.
"I was surprised by the percentage of people [living with HIV] that knew their partners were negative," said Pinkney. "I would think that once people found out they were HIV positive, that the relationship would end -- but they were just continuing and growing and planning a family," she said.
Although a majority of patients knew they were in a serodiscordant relationship, few had ever heard of PrEP as a prevention option. Overall, 93% of surveyed patients were not aware of PrEP and its benefits, Pinkney reported.
"There are lots of social and financial barriers" to PrEP uptake, said Pinkney. As well, she noted that PrEP isn't really advertised to heterosexual couples, as a majority of the focus tends to be on men who have sex with men.
"It's not something that's really addressed in the Caribbean," said Pinkney. "No one is really thinking about how to prevent transmission in that kind of group."
Doctors and public health officials who work in HIV are aware of the myriad of barriers to PrEP uptake across the globe. In fact, many of these key barriers -- which include a wide range of social and political dimensions -- were described in a 2015 summary of PrEP Implementation Science, published in the Journal of the International AIDS Society.
Related: First U.S. Failure of Truvada as PrEP Is Reported at IDWeek
The cost of PrEP is perhaps the most important barrier for low-income countries. In Jamaica, PrEP isn't covered by national formularies, and it's prohibitively expensive for many who need it, Pinkney noted.
In the U.S., the price of the drug skyrocketed 45% after it was approved to prevent HIV transmission, in addition to its other use as a treatment for people who are already living with HIV. While a generic version is available in many countries (in the U.S., it is available only for treatment, not prevention), access is spotty.
TheBodyPRO spoke with Orlando Harris, Ph.D., R.N., M.P.H., with University of California at San Francisco, who did not attend IDWeek but is also a researcher in HIV prevention and treatment in Jamaica. He said that in Jamaica, HIV treatment is covered by the government through the Ministry of Health at no-out-of-pocket cost to people living with HIV. The government recently completed an assessment of interest in and acceptability of PrEP among Jamaicans, and it is now in the process of implementing PrEP, although some private providers are already writing prescriptions for the use of HIV prevention.
For Pinkney, her research represents an encouraging sign that patients are very interested in this HIV prevention strategy. In addition to her top-line findings about the lack of awareness of PrEP, Pinkney also learned that patients were more willing to disclose their HIV status to a partner if they were "of reproductive age" -- essentially, if they were considering having children.
In fact, her research was inspired by the sheer number of her HIV patients who asked her how to best protect their partners -- a question that came up most often among patients who wanted to conceive.
"When you get that question repeatedly, you're like, OK -- do they know that PrEP is available?" she said. Obviously, her study found that a majority of patients were not aware of PrEP.
However, she also found that once HIV-negative partners were informed, "they were 100% interested" in the pill.
Pinkney concluded that among serodiscordant couples that want to conceive, stigma is unlikely to be a major barrier to PrEP uptake. If the drug is affordable and accessible, many people will want to use it, she said.