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Optimizing PrEP Selection and Persistence for MSM

Jason E. Farley, PhD, MPH, ANP-BC, FAAN, FAANP, AACRN

Professor
School of Nursing
Johns Hopkins University
Nurse Practitioner
Department of Infectious Diseases
John G. Bartlett Specialty Practice
Baltimore, Maryland


Jason E. Farley, PhD, MPH, ANP-BC, FAAN, FAANP, AACRN, has no relevant financial relationships to disclose.


View ClinicalThoughts from this Author

Released: December 14, 2022

Key Takeaways

  • Healthcare professionals have a major role in helping patients feel comfortable sharing about their sexual health and history.
  • Shared decision-making in an open and sex-positive environment is essential for PrEP uptake.
  • Patient follow-up and support are 2 key ways that healthcare professionals and their teams can promote PrEP persistence.

New HIV infections disproportionately occur in men who have sex with men (MSM), particularly Black and Hispanic men. Although there has been a significant increase in pre-exposure prophylaxis (PrEP) uptake across the United States in the past 10 years, PrEP use remains low in racial and ethnic minority MSM.

Conversations About Sexual Health and the Choice of PrEP
Healthcare professionals (HCPs) have a significant role in facilitating comprehensive sexual health conversations with their patients, regardless of their sexual orientation or risk for HIV acquisition. HCPs can open the dialogue about sex and sexuality as it relates to overall health and well-being by demedicalizing the conversation and centering it on sexual pleasure. This will help patients feel more comfortable talking about their risk factors for acquiring HIV.

When initiating PrEP, it is essential to use shared decision-making to select a PrEP option that works for each patient and their lifestyle to ensure maximal adherence. Some patients may prefer pills, whereas others prefer long-acting injections, so it is important to find out each person’s preference. It also is important that the patient has consistent access to PrEP and that the medication selected will be covered by the person’s insurance or through an assistance program.

One assistance program through the US Department of Health and Human Services, called “Ready, Set, PrEP,” provides free oral PrEP to people who earn less than $57,000 per year. The application process is easy and can be completed by clinic staff or community health workers, and no health insurance coverage is required. Patients need a negative HIV test result and a prescription for PrEP. Access—including to long-acting injectable PrEP—also can be facilitated through manufacturers’ patient assistance programs.

Barriers to PrEP Persistence
Fewer than 40% of people prescribed PrEP use it persistently at 12 months, limiting the overall effectiveness of PrEP at preventing the spread of new HIV infections in the community. To ensure that patients are diagnosed with HIV early if they do stop taking PrEP and become infected, I tell all my patients to come in every 90 days for a sexual health evaluation.

One factor complicating PrEP persistence is that a person’s risk level for HIV infection does not remain constant. I have many patients who will go from a relationship that was a one-time event to one that subsequently becomes much more monogamous. At this point, the person is likely to forego PrEP, but they feel a huge chasm when the relationship ends due to shame and stigma. As a result, many people do not reengage with the clinic. So, as soon as a patient says they plan to stop PrEP, we set up follow-ups for HIV and sexually transmitted infection (STI) testing and give them an open-door welcome to return for more PrEP should they need it again in the future.

Promoting Persistence
In my PrEP program, we use various methods to promote PrEP persistence. Our first approach is to make ourselves as accessible as possible. Our patients receive the phone numbers of the nurses, medical assistants, and prescribers to directly text us. They also can reach out through their electronic medical record with refill requests and STI testing or other issues.

Our second approach is to ensure a welcome, open, sex‑positive environment. No matter the person’s circumstances and choices, we maintain a sense of humility and grace so that conversations are not stigmatizing or shaming.

The third approach we take is to offer short telemedicine visits. We try to be as flexible with on‑demand scheduling as possible. This is not real time, but patients often can see us within 48 hours. During the 48‑hour period, we mail the patient a self‑collection kit for testing to get that started before the appointment.

Finally, we take advantage of community health workers, who can engage our patients in ways I and my nurses cannot. They help patients reschedule missed visits and do their routine lab collections. This is particularly important for patients receiving long-acting cabotegravir, because there is only a small window for a patient to receive their next injection and still be considered adherent to the regimen. For people who miss an injection, we double down on reengaging with text messages and phone calls. Our community health workers are vital to being able to reengage patients receiving PrEP and increase the accessibility of our clinic.

Your Thoughts?
What challenges have you encountered in selecting and encouraging the persistent use of PrEP in MSM? Join the discussion by posting a comment.

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