By Marie Rosenthal, MS
Preexposure prophylaxis (PrEP) is a cornerstone of America’s attempt to end HIV in this country, but only about 25% of people with a PrEP indication are receiving it, explained Tam C. Phan, PharmD, AAIVP, at the Academy of Managed Care Pharmacy (AMCP) Nexus 2022 meeting, in National Harbor, Md.
Most of the users of PrEP are men who have sex with men (MSM), especially white men, but some people, particularly adolescents, Blacks and Hispanics, cisgender and transgender women, and people who inject drugs, are at high risk for HIV exposure but slow to embrace prophylaxis, according to Dr. Phan, an assistant professor of clinical pharmacy USC School of Pharmacy, in Los Angeles.
Even among MSM, people of color have a much higher risk for contracting HIV in their lifetime, added Kevin Astle, PharmD, BCPS, BCACP, AAIVP, CDCES, an assistant professor at the University of South Florida, in Tampa. Hispanic MSM have a 1-in-4 chance of contracting HIV, which is three times higher than white MSM, and Blacks have a 1-in-2 chance of contracting HIV during their lives.
Dr. Astle noted that the CDC has taken a “holistic approach” in its 2021 updated guidelines for who should receive PrEP. With the broader guidelines, about 1.5 million people are likely to benefit from PrEP, he added, but there are racial and other disparities. For instance, PrEP coverage is almost eight times better for white patients than for Blacks, and only about 10% of females who would benefit from PrEP are receiving it.
“In our current guidelines, we really took a revolutionary approach to not focus on just high-risk populations, but looking at anybody who has had multiple sexual partners in the previous six months,” Dr. Astle explained. “That doesn’t define men who have sex with men, any kind of sexual orientation or put any standards on those relationships.
“Anybody who has multiple sexual partners in the last six months, anybody who is at continued risk for HIV infection, such as sera-discordant couples, as well as anybody who engages in those high-risk behaviors for HIV, anybody with inconsistent condom use and injection drug users” are PrEP candidates, he added.
Overcoming Barriers
Both provider and patient barriers exist, according to Dr. Phan. Providers may be uncomfortable managing PrEP or talking with patients about sexual health, and sometimes there are provider biases about a person’s color, sexual identity or lifestyle. On the patient side, lack of awareness and access, stigma, mistrust of the medical establishment, adherence, adverse events, and competing priorities such as financial needs can keep people from receiving PrEP, he said.
Some of these barriers can be overcome with education if providers take the time to talk with people and establish a trusting relationship, according to Dr. Astle. This means that some providers have to overcome their own biases about patients who require PrEP and ensure they offer it to those who could benefit.
This is one area were pharmacists can help, because they are the trusted medical health professional and they can spend a little more time with patients than a physician who has a 15-minute time slot for each patient.
Education for both providers and patients is essential, he added.
“Many patients who have a negative experience in healthcare typically tend not to return,” Dr. Phan said. “We need to provide an affirming environment.”
Other ways to overcome barriers is to have community advocates, higher more minority healthcare professionals and provide positive messaging to patients through social networks and social media “to improve knowledge and attitudes and reduce stigma,” Dr. Phan said. “We know there are effective prevention strategies for HIV, and the future continues to provide us with hope.”
