Primary Care Can Lead Way to HIV Prevention
Dr Matthew M. Hamill
HIV continues to be a significant public health concern in the United States, with an estimated 1.2 million people currently living with the virus and more than 30,000 new diagnoses in 2020 alone.
Primary care clinicians can help decrease rates of HIV infection by prescribing pre-exposure prophylaxis to people who are sexually active.
But many do not.
“In medical school, we don’t spend much time discussing sexuality, sexual behavior, sexually transmitted infections, and such, so providers may feel uncomfortable asking what kind of sex their patient is having and with whom, whether they use a condom, and other basics,” said Matthew M. Hamill, MBChB, PhD, MPH, a specialist in sexually transmitted diseases at Johns Hopkins Medicine in Baltimore, Maryland.
PrEP (pre-exposure prophylaxis) is an antiviral medication that cuts the risk of contracting HIV through sex by around 99% when taken as prescribed, according to the Centers for Disease Control and Prevention (CDC).
“Many people who would benefit from PrEP are not receiving this highly effective medication,” said John B. Wong, MD, a primary care internist and professor of medicine at Tufts University in Boston, Massachusetts. The gap is particularly acute among Black, Hispanic, and Latino people, who are significantly more likely to be diagnosed with HIV but are much less likely than Whites to receive PrEP, he said.
Dr John B. Wong
Wong, a member of the US Preventive Services Task Force (USPSTF), helped write the group’s new PrEP recommendations. Published in August, the guidelines call for clinicians to prescribe the drugs to adolescents and adults who do not have HIV but are at an increased risk for infection.
“Primary care physicians are ideally positioned to prescribe PrEP for their patients because they have longitudinal relationships: they get to know their patients, and hopefully their patients feel comfortable talking with them about their sexual health,” said Brandon Pollak, MD, a primary care physician and HIV specialist at The Ohio State University College of Medicine in Columbus.
Pollak, who was not involved with the USPSTF recommendations, cares for patients who are heterosexual and living with HIV.
Clinicians should consider PrEP for all patients who have sex with someone who has HIV, do not use condoms, or have had a sexually transmitted infection within the previous 6 months. Men who have sex with men, transgender women who have sex with men, people who inject illicit drugs or engage in transactional sex, and Black, Hispanic, and Latino individuals also are at increased risk for the infection.
“The vast majority of patients on PrEP in any form sail through with no problems; they have regular lab work and can follow up in person or by telemedicine,” Hamill said. “They tend to be young, fit people without complicated medical histories, and the medications are very well-tolerated, particularly if people expect some short-term side effects.”
What You Need to Know When Prescribing PrEP
Dr Jill S. Blumenthal
Prescribing PrEP is similar in complexity to prescribing hypertension or diabetes medications, Hamill said.
Because taking the medications while already infected with the virus can lead to the emergence of drug-resistant HIV, patients must have a negative HIV test before starting PrEP. In addition, the USPSTF recommends testing for other sexually transmitted infections and for pregnancy, if appropriate. The task force also recommends conducting kidney function and hepatitis B tests, and a lipid profile before starting specific types of PrEP.
HIV screening is also recommended at 3-month intervals.
“Providers may order labs done at 3- to 4-month intervals but only see patients in clinic once or twice per year, depending on patient needs and risk behaviors,” said Jill S. Blumenthal, MD, associate professor of medicine at UC San Diego Health, California.
Clinicians should consider medication adherence and whether a patient is likely to take a pill once a day or could benefit from receiving an injection every 2 months. Patients may experience side effects such as diarrhea or headache with oral PrEP or soreness at the injection site. In rare cases, some of the drugs may cause kidney toxicity or bone mineral loss, according to Hamill.
Three similarly effective forms of PrEP approved by the US Food and Drug Administration (FDA) enable clinicians to tailor the medications to the specific needs and preferences of each patient. Truvada (emtricitabine and tenofovir disoproxil fumarate) and Descovy (emtricitabine and tenofovir alafenamide) are both daily tablets, although the latter is not advised for people assigned female sex at birth who have receptive vaginal sex. Apretude (cabotegravir), an injectable agent, is not recommended for people who inject illegal drugs.
Patients with renal or bone disease are not good candidates for Truvada.
“Truvada can decrease bone density, so for someone with osteoporosis, you might choose Descovy or Apretude,” Pollak said. “For someone with chronic kidney disease, consider Descovy or Apretude. “If a patient has hepatitis B, Truvada or Descovy are appropriate because hepatitis B is treatable.”
Patients taking an injectable PrEP may need more attention because the concentration of the medication in the body decreases slowly and may linger for many months at low levels that don’t prevent HIV, according to Hamill. Someone who acquires HIV during that “tail” period might develop resistance to PrEP.
New research also showed that Descovy users were at elevated risk of developing hypertension and statin initiation, especially among those over age 40 years.
Primary care physicians may want to consult with renal specialists about medication safety in patients with severe kidney disease or with rheumatologists or endocrinologists about metabolic bone disease concerns, Hamill said.
Meanwhile, if a person begins a monogamous relationship and their risk for HIV drops, “it’s fine to stop taking PrEP tablets,” Pollak said. “I would still recommend routine HIV screening every 6 or 12 months or however often, depending on other risk factors.”
Dr Brandon Pollak
Caring for these patients entails ensuring labs are completed, monitoring adherence, ordering refills, and scheduling regular follow-up visits.
“For the vast majority of patients, the primary care physician is perfectly equipped for their care through the entire PrEP journey, from discussion and initiation to provision of PrEP,” and most cases do not require specialist care, Hamill said.
However, “If PrEP fails, which is exceedingly rare, primary care physicians should refer patients immediately, preferably with a warm handoff, for linkage to HIV care,” Blumenthal said.
Talking about PrEP opens the door to conversations with patients about sexual health and broader health issues, Hamill said. Although these may not come naturally to primary care clinicians, training is available. The National Network of STD Clinical Prevention Training Centers, funded by the CDC, trains providers on how to overcome their anxiety and have open, inclusive conversations about sexuality and sexual behaviors with transgender and gender-diverse, nonbinary people.
“People worry about saying the wrong thing, about causing offense,” Hamill said. “But once you get comfortable discussing sexuality, you may open conversations around other health issues.”
Barriers for Patients
The task force identified several barriers to PrEP access for patients because of lack of trusting relationships with healthcare, the effects of structural racism on health disparities, and persistent biases within the healthcare system.
Racial and ethnic disparities in HIV incidence persist, with 42% of new diagnoses occurring among Black people, 27% among Hispanic or Latino people, and 26% among White people in 2020.
Rates of PrEP usage for a year or longer are also low. Sometimes the patient no longer needs PrEP, but barriers often involve the costs of taking time off from work and arranging transportation to clinic visits.
Dr Mehri S. McKellar
Although nearly all insurance plans and state Medicaid programs cover PrEP, if a patient does not have coverage, the drugs and required tests and office visits can be expensive.
“One of the biggest barriers for all providers is navigating our complicated health system and drug assistance programs,” said Mehri S. McKellar, MD, associate professor of medicine at Duke University School of Medicine in Durham, North Carolina.
But lower-cost FDA-approved generic emtricitabine/tenofovir disoproxil fumarate is now available, and clinicians can direct patients to programs that help provide the medications at low or no cost.
“Providing PrEP care is straightforward, beneficial, and satisfying,” Hamill said. “You help people protect themselves from a life-changing diagnosis, and the health system doesn’t need to pay the cost of treating HIV. Everyone wins.”
Hamill, McKellar, Pollak, and Wong, have reported no relevant financial relationships. Blumenthal has reported a financial relationship with Gilead Sciences.
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