For the first time in four years, the Centers for Disease Control and Prevention (CDC) last month issued updates to the HIV Preexposure Prophylaxis (PrEP) Clinical Practice Guidelines and Providers Supplement, changes that broaden criteria for who may be offered PrEP and include expanded ways to use it. Additions include options that weren’t available when the 2017 PrEP guidelines were written, notably telehealth for PrEP and intramuscular cabotegravir (CAB LA) injections, expected to be approved by the Food and Drug Administration (FDA).
Telehealth, or TelePrEP, has surged during the pandemic, and inclusion of once-every-other-month injectable CAB LA in the draft guidelines is a nod to imminent FDA approval. The yet-to-be finalized guidelines also show that Truvada “on demand” before and after sex, aka PrEP 2-1-1, is equally effective for men who have sex with men (MSM) and may be used off-label—something many people have already been doing.
The draft guidelines still recommend daily emtricitabine/tenofovir disoproxil fumarate (Truvada) dosing for all adults and adolescents at risk of HIV, although the updates note that daily emtricitabine/tenofovir alafenamide (Descovy) is an option for sexually active men and transgender women and, due to insufficient data, FDA approval of Descovy for PrEP does not include people engaged in receptive vaginal sex.
The CDC is also advising clinicians to discuss PrEP with all sexually active adults and adolescents, as well as people who inject drugs, regardless of their sexual activity. The guidelines acknowledge that the active ingredient TDF in Truvada can cause kidney impairment and that testing of renal functions should be conducted periodically—every six months for people over age 50—and that triglyceride levels and weight gain should be monitored at least twice a year for those taking Descovy.
More PrEP Options, but Uptake Depends on Clinicians
When used as prescribed, PrEP reduces the risk of getting HIV from sex by about 99%. But nearly a decade after the first HIV antiviral treatment was approved for HIV prevention, the uptake has been dismal. A CDC surveillance report released in May 2021 determined that in 2019, less than a quarter of Americans eligible for PrEP (23%) were prescribed it. There were also marked racial disparities: While 63% of eligible white people were prescribed PrEP, only 8% of Black people and 14% of Latinx people who were eligible for PrEP were prescribed it.
Ken Mayer, M.D., medical research director of the LGBTQ health care nonprofit Fenway Health and a professor of Medicine at Harvard Medical School, believes the CDC PrEP guidance changes are good but will only be effective if they help more doctors start the conversation about sexual health.
“Doctors don’t always read guidelines,” said Mayer. “If the CDC is serious about increasing PrEP use, to make their national strategy real, they will get trainers out to meetings and increase demand [for PrEP] through social influencers. But I don’t recall that they did a lot of activity around the 2017 guidelines.”
In the past, cities have encouraged vulnerable populations to ask about PrEP; for example, a 2018 San Francisco Health Department effort promoted PrEP to Black Americans. And the CDC does offer PrEP information for clinicians, should they want to access it. But aside from AIDS Education and Training Center (AETC) for providers and sessions at national conferences, it’s easy for primary care providers to miss out on PrEP education, said Mayer.
Mayer described the paradox in which clinicians are—and aren’t—learning about PrEP and prescribing it. “PrEP has been an orphan, because you have HIV specialists who know about treatment, then generalists who say, ‘I’m not an HIV specialist, and therefore I don’t prescribe (ART),’” he said.
Beyond clinicians’ siloed thinking about HIV and sexual health options, a general lack of knowledge of PrEP and reluctance to talk about sex can be another barrier to PrEP use. A review published last year in AIDS Patient Care and STDs said physicians’ lack of knowledge about PrEP, as well as their personal values related to sex, prevented them from discussing sexual behavior with patients and prescribing PrEP. And according to a survey in PLOS One, also from last year, even among “highly motivated” practitioners who attended continuing education focused on HIV, only 54% had ever prescribed PrEP. Similarly, a 2016 survey of eligible physicians in Washington state found that less than two-thirds had even heard of PrEP.
Janessa Broussard, M.S.N., RN, AGNP-C, vice president of medical affairs at San Francisco AIDS Foundation, said that, while she’s impressed with the CDC’s proposed PrEP guidance changes, mainly because of the individualized options for PrEP use, she agreed with Mayer that increasing PrEP uptake relies on clinicians’ willingness to talk with clients about sexual health.
“If someone tests positive for rectal gonorrhea, for example, that client should not leave without a discussion of PrEP,” said Broussard. “But if PrEP is only addressed in HIV clinics or sexual health clinics or LGBTQ clinics, many opportunities to inform people [about PrEP] will be missed. And there are communities who don’t feel comfortable going to an HIV or LGBTQ clinic.” And, too, there are wide swaths of the U.S. without LGBTQ or sexual health clinics.
Broussard added that pediatricians are also key to getting teens engaged in a conversation about sexual health. But because primary care doctors have a lot of health ground to cover in what are often short appointments, talking about sexual health might fall to the bottom of the list, even in San Francisco, said Broussard. “And this is not a conservative area, where there may be very different views about talking about sexual health, or even whether it’s appropriate for the government to pay [for PrEP].”