PrEP Saves Lives, Remains Inaccessible for Many Patients

When taken daily, pre-exposure prophylaxis, or PrEP, can reduce the risk of HIV transmission in men who have sex with men by nearly 90 percent.1King HL, Keller SB, Giancola MA, Rodriguez DA, Chau JJ, Young JA, et al. Pre-exposure prophylaxis accessibility research and evaluation (PrEPARE Study). AIDS Behav. 2014;18(9):1722-5. Epub 2014/07/16. doi: 10.1007/s10461-014-0845-5. PubMed PMID: 25017425; PubMed Central PMCID: PMCPMC4127131. Given the large global burden of HIV/AIDS–which was still the eighth leading cause of early death worldwide in 2017 despite reductions in mortality–one might suspect PrEP to be an integral part of the public health arsenal.2Collaborators GBDRF. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1923-94. Epub 2018/11/30. doi: 10.1016/S0140-6736(18)32225-6. PubMed PMID: 30496105; PubMed Central PMCID: PMCPMC6227755. However, PrEP is largely under-prescribed by providers and is not often sought out by patients, with particularly large prescribing disparities affecting racial minority patients.3Krakower D, Mayer KH. Engaging healthcare providers to implement HIV pre-exposure prophylaxis. Curr Opin HIV AIDS. 2012;7(6):593-9. Epub 2012/10/04. doi: 10.1097/COH.0b013e3283590446. PubMed PMID: 23032736; PubMed Central PMCID: PMCPMC3769645. Though such data can seem as overwhelming as they are alarming, providers have an important role to play in reducing the structural barriers to PrEP access and, consequently, the transmission of HIV.

Being a PrEP-ared provider

Breaking down the barriers to PrEP access begins with provider education. A CDC report from 2015 showed that one in three providers, including physicians and nurses, had never heard of PrEP.4Centers for Disease C, Prevention. HIV prevalence estimates–United States, 2006. MMWR Morb Mortal Wkly Rep. 2008;57(39):1073-6. Epub 2008/10/03. PubMed PMID: 18830210. When it comes to prophylactic treatment for a disease with such a large global health burden, such blatant lack of awareness is unacceptable. In another study, nearly 60 percent of primary care provider discussions about PrEP were initiated by patients.5Petroll AE, Walsh JL, Owczarzak JL, McAuliffe TL, Bogart LM, Kelly JA. PrEP Awareness, Familiarity, Comfort, and Prescribing Experience among US Primary Care Providers and HIV Specialists. AIDS Behav. 2017;21(5):1256-67. Epub 2016/11/26. doi: 10.1007/s10461-016-1625-1. PubMed PMID: 27885552; PubMed Central PMCID: PMCPMC5500978. These numbers point to an obvious need for HIV-related public health initiatives that seek to educate providers as well as patients about appropriate prophylactic options.

Providers who have adopted PrEP in their practice can serve on the front line of such initiatives by being a vocal social marketer of the drug, leading by example by advocating for its use both to colleagues and on social media. Inter-colleague education should include brief yet concrete information on PrEP’s mechanism of action, dosing regimen, and follow-up assessments.

Providers can play an important role in mitigating the costs of PrEP for their patients.

For those who haven’t already built a PrEP-inclusive practice, there are a number of ways to move toward this goal. First, primary care providers should incorporate regular HIV screening on intake forms in order to identify patients who are at increased risk, all of whom should be tested for HIV. These risk factors might include: being a man who has sex with men, evidence or risk of hepatitis B or C infection, illicit drug use, sexually transmitted diseases, and homelessness.

When talking to these patients, providers should use language that is familiar in order to mitigate patient anxiety or discomfort. For instance, when talking to a patient that identifies as gay, consider using the words “top” and “bottom” to describe penetrative and receptive anal sex, respectively. Once a provider has established a method of identifying patients for which PrEP might be useful, they should incorporate a level of self-directed learning about the drug. Organizations like the AIDS Education and Training Center offer myriad online webinars, pamphlets, and videos geared toward providers.

The high cost of a lifesaving medication

The high cost of PrEP also perpetuates its inaccessibility. Since the drug was approved in 2012, the drug’s price has increased nearly 45 percent to almost $2,000 per month, out of pocket. Considering that HIV prevalence rates are inversely associated with household income and socioeconomic status, such high costs can make PrEP an infeasible option for many patients living with HIV.6Centers for Disease C, Prevention. HIV prevalence estimates–United States, 2006. MMWR Morb Mortal Wkly Rep. 2008;57(39):1073-6. Epub 2008/10/03. PubMed PMID: 18830210. In fact, several studies show that the cost of PrEP is consistently cited as a major barrier for patients seeking HIV prophylactic treatment.7King HL, Keller SB, Giancola MA, Rodriguez DA, Chau JJ, Young JA, et al. Pre-exposure prophylaxis accessibility research and evaluation (PrEPARE Study). AIDS Behav. 2014;18(9):1722-5. Epub 2014/07/16. doi: 10.1007/s10461-014-0845-5. PubMed PMID: 25017425; PubMed Central PMCID: PMCPMC4127131.,8Jaiswal J, Griffin M, Singer SN, Greene RE, Acosta ILZ, Kaudeyr SK, et al. Structural Barriers to Pre-exposure Prophylaxis Use Among Young Sexual Minority Men: The P18 Cohort Study. Curr HIV Res. 2018;16(3):237-49. Epub 2018/08/01. doi: 10.2174/1570162X16666180730144455. PubMed PMID: 30062970.

Providers can play an important role in mitigating the costs of PrEP for their patients. Several programs exist to reduce the cost burden of PrEP. Gilead, the company that manufactures PrEP, offers $7,200 towards co-pay and deductible costs through its Advancing Access copay assistance program–helpful for patients with private insurance for whom the reduced price of the drug might still be too expensive. Patients without insurance or those enrolled in a federal or state-funded healthcare benefit program like Medicaid can apply for the Medication Assistance Program (MAP), which provides free prescription drugs for 12 months to those making less than 500 percent of the federal poverty line.

Both programs have simple applications that can be completed in clinic, minimizing concerns regarding patient health literacy. For the Gilead co-pay program, physicians can call 1-877-505-6986 or visit their website. For MAP, providers should call 1-855-330-5479.

Prophylactic medications like PrEP are extremely efficacious in preventing transmission of HIV in high-risk populations. However, PrEP is too often inaccessible to those who need it most. Through physician education and cost reduction programs, providers can play an important role in decreasing the global incidence and health burden of HIV.

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Keith Luckett, M.D.

Dr. Luckett is Associate Professor of Internal Medicine at the University of Cincinnati College of Medicine.

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