In large U.S. cities, many people have gotten used to social marketing campaigns on public transit and billboards at major intersections touting messages about HIV prevention and treatment, including PrEP (pre-exposure prophylaxis). But those who ask their providers about PrEP are still often told things that discourage them:
"PrEP is for gay men."
"You're a nice girl; you don't need PrEP."
"You're married, so PrEP isn't for you."
"You need to see an HIV specialist for that."
It's true that the way PrEP was initially introduced to most communities, it seemed as though PrEP was only for gay men or people with a lot of sex partners -- so it's no wonder PrEP prescriptions for women have been low. But New York City is trying to change that. On May 9, 2019, the New York City Department of Health and Mental Hygiene (NYC DOHMH) launched a new campaign targeted at educating women's health providers, including family planning, OB/GYN, and primary care providers, about the medications HIV-negative women can take to stay HIV negative.
In 2017, about 2,157 New Yorkers were diagnosed with HIV, which was a decrease from 2016. The overall number of women diagnosed with HIV (a figure that includes cisgender and transgender women) also declined in 2017 from the previous year, although black and Latina women represented 90% of all women who were diagnosed. But according to data shared by health department officials at the event, only 34% of sexually active black and Latina women in New York City were aware of PrEP. In the first half of 2018, only 1,300 women were prescribed PrEP in New York City, compared to 16,000 men.
"This is really unacceptable," said Oni Blackstock, M.D., assistant commissioner for the Bureau of HIV/AIDS Prevention and Control at NYC DOHMH, "and shows more needs to be done around improving awareness and access to the full prevention toolkit, including PrEP." Blackstock and others spoke at a campaign launch announcement held in the Manhattan headquarters of the HIV service organization God's Love We Deliver.
To address this problem, the campaign will take a page from the playbook of pharmaceutical sales, and employ a process called "detailing." Detailing entails sending trained individuals out to meet with a targeted list of medical providers -- usually with the intent to educate providers on the uses of certain medications, with the often unstated goal of persuading them to make prescriptions. In this case, they'll be using the same techniques to familiarize providers with PrEP and PEP (post-exposure prophylaxis), how to prescribe these drugs, and how to provide long-term care and support to patients who are using PrEP. Providers will also receive a newly designed action kit for women. NYC DOHMH is working with a company called On Call, which provides detailing services to pharmaceutical companies as well as public health agencies.
Blackstock noted that they'll be advising providers who receive the toolkit to take a different kind of sexual history -- one that focuses less on specific sexual acts or number of partners, and more on issues like histories of sexual abuse or intimate partner violence, being involved in sex work, or having an STI (sexually transmitted infection).
"As we all know, PrEP is an incredible tool in the fight against HIV," said Dena Kranzberg, RN, WHNP-BC, director of training with Planned Parenthood of New York City, one of the city's partner organizations for this campaign. "And chief among our responsibilities as health care providers is sending the resounding and direct message that PrEP is for all women, specifically black, Latina and trans women."
Fleur De Kine is a black woman who moved to New York in 2015; she saw the subway ads for NYC's "Play Sure" campaign with a friend.
"I was new to New York City, and I wanted to play sure," she said. She and her friend discussed starting PrEP, but delayed going to the doctor -- until that same friend tested positive for HIV. He encouraged her to get on PrEP, while he focused on getting virally suppressed. They both entered care the same day.
De Kine discussed many of the challenges she's faced since she began taking PrEP in 2016 -- whether it was her experiences with providers who thought PrEP was only for gay men, or marked on her medical chart that she was HIV positive because she said she was on Truvada. She also talked about how a person being ranked as "high risk" for the kind of sex they're having can create a form of stigma, while as a sexually active person it's simply an expression of their desire and a way to have pleasure and fun. She recommended a much more direct and streamlined approach.
"I went through the packet that doctors get, and four lines down [where it discusses] how to assess who should get [PrEP], it asks: 'Are you sexually active?'" said De Kine. "And I'm like, 'Shouldn't that question be at the top?'"
Her final advice for doctors? Educate patients, and provide access.
"Bring it up to everybody," De Kine concluded. "Just let them know, and give them the tools to make their own decisions."