Delegates to the 10th International Conference on HIV Treatment and Prevention Adherence were provided information on a variety of issues concerning the uptake and effectiveness of, barriers to, and facilitators for pre-exposure prophylaxis (PrEP) as a biomedical intervention to prevent the spread of HIV. Despite media campaigns warning of adverse consequences, more than 20,000 people are now on PrEP and significant trends are emerging regarding who is adopting it, how it is being used and what remains to be done in order to make PrEP available to those populations at highest risk for HIV infection. Kenneth Mayer, M.D., emphasized a theme consistently underscored at the conference: PrEP works, but adherence is the key.
Several years after the approval of tenofovir/emtricitabine (Truvada) for use as PrEP, demographic patterns regarding uptake are emerging. More whites are willing to take it, as are people with more education, while fewer older people plan on taking it. Overall, uptake of the currently available oral version has increased 312% from 2012 to 2014, a significant trend reflective of increased awareness, acceptance and availability. Increases in adherence seem to correspond with more people utilizing PrEP. Among 2014 starters, for example, adherence was better than among people who initiated it in prior years.
Many gay and bisexual men, one of the highest-risk demographic groups, have embraced PrEP. Robert Grant, M.D., M.P.H., reported that, in San Francisco, two-thirds of men reporting high sexual risk (defined as more than six recent partners) are on PrEP, while uptake among the "worried well" hasn’t been as great. Interestingly, several researchers, including Andrew Petroll, M.D., M.S., reported that risk compensation (adjusting behavior following changes in perceived risk) for gay and bisexual men on PrEP is low. In other words, they do not act out sexually and, as reported by Sarit Golub, Ph.D., M.P.H., may actually be less sexually compulsive. Not only is intention to initiate PrEP high among gay and bisexual men, but also among other demographic groups in which HIV is most concentrated: youth, men of color, people with lower socioeconomic status and people engaging in sexual risk. According to one researcher from the University of Wisconsin, of the men who want PrEP, more than 50% initiate it within three months, and 80% initiate it within six months.
Numerous barriers affect the acceptance and availability of PrEP, not the least of which is cost, although most insurance carriers are covering the drug in their formularies. Study participants who were considering initiating PrEP reported other barriers, such as concern about health consequences, as well as both provider and social stigma. The inconvenience of having to take the medication daily was another expressed concern, affecting both adherence and effectiveness. There seems to be some forgiveness with tenofovir/emtricitabine whereby antiviral protection remains consistent despite missed doses, a promising result emerging in ongoing research. As many as 80% of potential PrEP users would prefer a long-acting injectable for convenience, according to one study by Katherine Meyers et al reported in PLOS ONE.
Provider acceptance in the medical community has been a concern affecting uptake, described by Douglas Krakower, M.D., Jennifer Mitty, M.D., M.P.H., and Mayer as the "purview paradox." This recognizes that those physicians in the best position to prescribe PrEP -- internal medicine, family practice -- are those with little or no expertise with the drug, while HIV providers who are familiar with antiretroviral therapy do not necessarily see persons who have not seroconverted. Krakower reported that the diffusion of PrEP into generalist practices could improve if effective trainings and decision-support tools were available, particularly if they incorporated guidance for complex prescribing scenarios. However, in one study, primary care providers also expressed concern about the realities of adding the time-consuming sexual discussions necessary to evaluate appropriateness for biomedical prevention intervention.
One high-risk population with unique barriers to the adoption of PrEP is the transgender community. Researchers noted the urgent need to disaggregate transgender women from men who have sex with men (MSM) in HIV-prevention strategies and develop transgender-specific facilitators for PrEP. Based on negative experiences, many in this community distrust health care providers and health care settings. Providing PrEP through the same trusted providers who prescribe hormones would be an effective strategy for this problem. Other concerns such as potential interactions with hormones, managing multiple medications and overall avoidance of medical settings, were reported as barriers to the adoption of PrEP in the transgender community.
Concern about adherence to PrEP has been a major theme among both researchers and social campaigns, yet research indicates high levels of adherence among MSM. In one study at the City University of New York, 69% of gay and bisexual men reported not missing any doses in the prior 30 days. Of those who missed a dose, 92% reported missing two or fewer doses. Nearly half of the study population (48%) reported not missing any doses in the past 90 days. The most common reason for missing a dose (48%) was simply forgetting, while 26% reported missing doses because they were away from home without their pills.
While behavioral interventions were consistently reported to increase adherence, PrEP was also shown to facilitate positive behavioral benefits. Golub, describing PrEP as a "gateway drug to primary care," reported its synergistic effect on primary care, insurance and mental health. Citing responses from the SPARK study at Callen-Lorde Community Health Center in New York, Golub reported a 29% increase in new insurance coverage, more sexual health conversations between providers and clients, and an overall improvement in psychological well-being, expressed as less perceived risk and HIV-related anxiety, and less anxiety and depression overall.
In summarizing the current state of PrEP, Grant described three key objectives to improve the acceptance and utilization of this biomedical prevention intervention. The first is the need to replace the concept of "risky people" with people who have "seasons of risk." This approach greatly diminishes stigma by redefining those who might need PrEP as "people just like us" who are moving in and out of risk. Examples of such individuals include new sex workers, people who have experienced the breakup of a relationship, or people using methamphetamine. A second objective stated by Grant is the need to be more than merely nonjudgmental about sexual behavior, instead celebrating an individual’s desired sexual goals. Discussions of sexual pleasure and intimacy need to be incorporated into prevention messages as a way to engage clients. As he noted, adherence depends on engagement, and the biggest problem with PrEP is disengagement from care. The third and final objective is the removal of any shame or stigma that makes adherence more difficult. Based on the findings of this conference, shame and stigma will diminish as data supplant any unfounded fears or myths that currently permeate discussions about PrEP.
David Fawcett, Ph.D., L.C.S.W., is a substance abuse expert, certified sex therapist and clinical hypnotherapist in private practice in Ft. Lauderdale, Florida.