We Need to Better Prep Our Patients with Pre-Exposure Prophylaxis (PrEP)

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Did you know that according to the Center for Disease Control (CDC), if current HIV rates continue, one in two (50%) African American men who have sex with men (MSM, includes Gay and bisexual men) will contract HIV infection before they are 40 years old? For Latino MSM, that figure is one in four (25%). For white MSM the number is 1 in 11. Since 2012, medication has been FDA approved to prevent HIV transmission, otherwise known as Pre-Exposure Prophylaxis (PrEP). Emtricitabine/tenofovir (Truvada), a one-pill per day option, can help change this worrisome statistic, but only 1% of Black Gay men are using it, and only 3% of Latino Gay men. As a PA in HIV care since 1992, I consider myself a PrEP missionary. I hope I can convert all primary care providers, that this is an emergency, and needs your immediate attention.

PrEP is up to 99% effective against HIV transmission if taken with excellent adherence. It is covered by many health insurances (otherwise, there are patient access programs through Gilead Pharmaceutical), and has few side effects. PrEP was first approved for HIV prevention 6 years ago. Why is it under-prescribed in Communities of Color? Homophobia? Stigma? Racism? Access to health care? PrEP is for people at significant risk of HIV infection. Studies have shown efficacy in Gay men, IV drug users, and heterosexual couples. It is targeted for those having unprotected sex with multiple sexual partners, and especially those who have had a Sexually Transmitted Infection (STI) in the past 6 months. In addition, HIV transmission is on the up-swing in the shadow of the opiate epidemic.

Reinforce ways to prevent HIV infection to your patients :

  1. Use condoms
  2. Decrease the number of sexual partners
  3. Never share needles
  4. Choose less risky sexual activities (such as oral sex, see CDC website for additional information)
  5. Avoid getting other STIs which can facilitate HIV transmission
  6. Use Post Exposure Prophylaxis (PEP) which is usually a 3 drug regimen to take after a risky exposure, such as unprotected sex with someone with un-treated HIV or sharing needles
  7. Most importantly, encourage HIV testing and facilitate treatment access right away, if positive. 1 in 6 Gay men with HIV have not been diagnosed.
  8. HIV treatment as prevention — persons with HIV who have an undetectable HIV viral load (a test that quantifies the HIV virus) for at least 6 months, have diminished the risk of transmission to almost zero.

There are few contra-indications to PrEP. The creatinine must be monitored, and other STIs are checked every 3 months while taking Truvada. Condom use has been shown to be diminished by those on PrEP, so the risk of other STIs may increase. Also, Hepatitis B status must be checked prior to starting Truvada, as it has activity against Hepatis B, which could then flair if the medication is stopped.

How can you help? Think about your patient population. Have all your Gay men and trans women been offered PrEP? Are you asking about sexual activities? Don’t assume hetero-normative unless you ask. Women should be asked about their sexual partners, especially minority women. 90% of HIV transmission in women is heterosexual exposure, and 10% IVDU. Most importantly, be sure to follow CDC guidelines regarding HIV testing. Offer it to all your patients once in their lifetime, and yearly for those who are at higher risk. Untreated HIV causes inflammation, cancers, and serious health effects. If you project a non-judgmental approach, this will go far to fight the stigma that results in fear of testing and treatment.

We can get to zero HIV transmissions with these interventions. Help join the fight!

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