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As providers, how can we ensure that we address barriers to PrEP uptake?
There has been an increase in PrEP prescribers in the United States between 2014 and 2019.36 In 2014, fewer than 1% of all US providers prescribed PrEP, and this rose to 4.3% in 2019. Prescribing by primary care physicians increased from 1.8% to 13.6%, and prescribing among infectious disease physicians rose from 14.2% to 34.2%.
The number of PrEP providers increased from 9621 in 2014 to 65,882 in 2019. The main PrEP providers were primarily still physicians (68%) in 2019, followed by nurse practitioners (21%), and physician associates/physician assistants (9%). Most PrEP is prescribed in urban areas (93%). In 2019, 52% of new HIV infections occurred in the South, the region that also accounted for the largest percentage of people with a PrEP indication (41%). PrEP provider capacity—the number of prescribers for every 100 people with a PrEP indication—was lowest in the South compared with the West, Midwest, and Northeast, which had the highest PrEP provider capacity.
Clearly, there is further progress to be made in expanding the number of providers able to prescribe PrEP, as well as increasing capacity in rural areas, particularly in the South, where these improvements may have greater impact.
In addition to the regional inequities in PrEP uptake in the United States, access is reduced in adolescents, Black and Latinx populations, cisgender women, TGW, and PWID.37,38
A range of measures have been proposed to address key barriers to PrEP uptake, including low awareness of PrEP availability or HIV risk, stigma, provider bias and mistrust of the healthcare system, poor access to medical care, lack of access to financial assistance, and adverse events.39 Potential approaches to removing these barriers include patient and provider education and better communication between providers and patients, including use of culturally appropriate messaging.
Improving cultural humility via education and advocacy and encouraging communication and mutual understanding between providers and patients can encourage trust and begin to address stigma. Provider education is needed to address systemic biases within healthcare systems, such as structural racism, that contribute to the health inequities observed in Black and Latinx populations and LGBTQ populations. Working to attract more healthcare professionals from these communities can assist in addressing these biases.
Access to medical care can be improved by extending access to PrEP in different prescriber settings, such as substance use clinics, emergency departments, correctional institutions, and pharmacies. In my home state of Illinois, legislation has been passed that will allow trained pharmacists to prescribe PrEP and order laboratory tests without a doctor’s order.
During the pandemic, we all have become adept at leveraging technology to improve access to care via telemedicine, which also can be adapted to improve access to PrEP. Understanding and addressing the social determinants of health in our at-risk populations—who may have competing priorities around food insecurity, safety concerns, transportation, and childcare—is also vital to enabling patients to access PrEP services.
Financial assistance is available for those who do not have insurance coverage for PrEP medications, along with access programs from medication manufacturers. Copay assistance and support to cover the costs of laboratory tests vary by state. Assistance with navigating the paperwork to access these programs often is needed.
Finally, healthcare professionals need to make sure patients understand that PrEP medications are safe and provide excellent protection from HIV infection. Ensuring that patients are aware of the type of adverse events that may occur and how to report them is important, as is recognizing the renal and weight-change considerations associated with particular PrEP medications.
The availability of LA injectable CAB has expanded PrEP options. Other forms of LA PrEP, such as vaginal rings, are under evaluation in resource-limited settings.40 In the future, implantable devices that release medications over longer periods of perhaps 6 months and up to 1 year may be available. Broadly neutralizing antibodies designed to stop HIV strains from replicating in human cells are in early-stage clinical investigation as HIV prevention tools.
Use of immediate antiretroviral therapy initiation in people newly diagnosed with HIV infection is recommended to reduce HIV-1 RNA and risk of onward transmission, as well as to link patients to care.41
The CDC PrEP guidelines also recommend procedures for immediate PrEP initiation on the same day as initial evaluation in select patients.4 This approach was first outlined through a study conducted in sexual health clinics in New York City.42 During a 2-year period from 2017-2018, 1437 adult PrEP candidates were assessed. Immediate PrEP was offered to anyone with a negative rapid HIV test and no reported kidney disease, hepatitis B infection, or symptoms of acute HIV. In total, 97% of candidates qualified for immediate PrEP. Fewer than 1% needed to stop PrEP because of a low estimated glomerular filtration rate or a positive HIV test result. Of importance, of the 3% of candidates who delayed PrEP, only 35% started PrEP later. This study really demonstrated the power of immediate PrEP provision upon expression of interest and upon first engagement in care for a PrEP evaluation.
There was a progressive decline in PrEP initiation between February 2020 and April 2020 at the start of the COVID-19 pandemic.43 Although this leveled out, there was not a return to prepandemic uptake levels by the end of 2020.
PrEP screening, initiation, and follow-up visits can be conducted by phone or web-based consultations with healthcare professionals.4 Laboratory specimens are needed for patient assessment and monitoring, but patients need only attend the laboratory for specimen collection; home specimen collection kits can be ordered for specific tests. Currently, patients receiving injectable PrEP will need to visit a clinic for injections every 8 weeks, but oral PrEP can be dispensed via pharmacies.
Providing the right type of PrEP for each patient can mean high levels of protection from HIV infection. New and emerging PrEP options are changing the landscape of PrEP use and should allow greater uptake of PrEP by those with significant unmet need.