Is PrEP Viable? Will Doctors Prescribe It? Are we too scared to ask for it?

B LarsonWilliam L. Larson, Pharm D.
Adherence Pharmacist, The Doctors, an Allina Clinic in Uptown

Lately I’ve been talking a lot about PrEP, or pre-exposure prophylaxis, to prevent HIV infection.  PrEP is taking a medication to prevent HIV infection, and Truvada was approved for this purpose by the FDA last year.  According to current guidelines, Truvada should be taken every day to prevent HIV infection in those for whom it is prescribed.

First, a little background about the HIV epidemic in the US:  Thirty-two years into the epidemic, and we still have 50,000 new HIV infections each year, a number which is holding steady.  Blacks account for 44% of new HIV infections, even though they represent 12% of the population.

I get a lot of different reactions when I talk about PrEP to Black community groups in Minneapolis.  People do not quite believe me when I tell them about PrEP and the studies that led to its approval, such as the iPREX study, CDC-TDF-2, or Partners PREP.  In fact, one participant became suspicious when I described the study design, wondering why they were giving Black participants in Africa a placebo if they knew they were at risk for becoming HIV infected.

Of course, this led us to discuss the ethics of clinical trials and the reasons for these studies in the first place:  to find out if PrEP works and how to use it most effectively.  Underlying this discussion, however, is a basic mistrust of our healthcare system.

Class participants then wanted to know how to access PrEP.  This is a fair question that I stumble through when attempting to answer.  The obvious answer is that you go to your doctor and ask for it, but it’s not that simple.  First, what if you do not have a doctor?  Or, what if your doctor is unfamiliar with PrEP?  Assuming you have a doctor, won’t he or she want to know why you are asking for it?  Are you having a lot of unprotected sex?  Aren’t you using a condom?   There would be plenty of opportunities for the doctor to insert shame or guilt about your sex life.   For some people, the stress of holding this conversation with their doctor might prevent them from even bringing it up.

If you do not have insurance, PrEP may be even more difficult to obtain.  PrEP involves more than just obtaining a bottle of pills.  It requires laboratory monitoring and doctor visits, which cost money.  I learned that some cities have established PrEP clinics funded by grants to make it easier to obtain PrEP.  Red Door Services in Minneapolis has started such a program for a limited number of gay men, but you must be referred to their HIM program to participate.

When I talk to my doctor colleagues in the clinic about PrEP, they have a different view on it.  According to them, they would prescribe it, but few patients are asking for it.  They believe that PrEP is just not that popular and most of their patients do not want it.

I have a different opinion about PrEP.  I think people are not asking for it because they don’t know what it is.  Many don’t understand HIV or their risks of becoming infected well enough to ask for PrEP.

I will continue to talk about PrEP and encourage people to use it and ask for it.  I believe we need to use every tool in our toolbox to prevent HIV infections, and just giving people a condom is not good enough.   A national surveys showed that most people do not use condoms consistently, and their use drops off with age. (Reece, M, et al. Condom Use Rates in a National Probability Sample of Males and Females Ages 14 to 94 in the United States, The Journal of Sexual Medicine. Volume 7, Issue Supplement s5, pages 266–276, October 2010)

I agree with “Jake Sobo” when he said in a recent article in that we all have an ethical duty to tell people about PrEP, including the health department, AIDS service organizations, and clinicians. To quote Jake, “Continuing to live in a condom fantasyland isn’t just willfully ignorant, it’s immoral.”