HIVR4P 2016: Some Americans Who Need PrEP the Most Face the Greatest Barriers

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The personal values and moral judgments of healthcare providers are likely to interfere with the appropriate provision of HIV pre-exposure prophylaxis (PrEP), Sarah Calabrese of Yale University reported at the HIV Research for Prevention conference (HIVR4P 2016) in Chicago last week. This was one of several presentations which highlighted inequalities in access to PrEP in the U.S. In a plenary talk, Noël Gordon of the Human Rights Campaign reminded delegates that white people make up 27% of new HIV diagnoses but 74% of PrEP users. There are also inequalities in terms of age and gender.

[Produced in collaboration with aidsmap.com]

When medical students were given hypothetical scenarios of gay men seeking PrEP, they were less willing to provide it to men who were not monogamous and to men who acknowledged not using condoms. Men at a lower risk of acquiring HIV had a greater chance of getting PrEP.

"It is critical that PrEP access be governed by science and not by personal values," Calabrese said.

Today’s medical students are tomorrow’s healthcare providers, she argued. Nonetheless, a limitation of the study is that it enrolled students before their training is complete and before they gain clinical experience.

Recruited online, 111 students at 2 medical schools in the northeast U.S. completed a brief survey. They were given background information on the evidence for PrEP, its approval by the Food and Drug Administration, and some arguments for and against it. The key question was, "Please rate how likely you are to prescribe to the patient described based on the information given."

The hypothetical patients all represented gay men at elevated risk of HIV. There were 6 scenarios were presented, varying 2 key elements.

For a gay man in a monogamous relationship with an HIV-positive man who was not on antiretroviral treatment, 93% were willing to prescribe PrEP if the couple planned to continue to use condoms. But if the monogamous couple were already not using condoms, only 53% would be willing to prescribe PrEP. And if the couple planned to stop using condoms if PrEP was provided, just 27% of medical students were willing to prescribe it.

"This pattern is paradoxical to patient risk," Calabrese commented. "The patient who is at lowest risk is the one who is going to sustain his condom use, but he is the person who has the best access to PrEP." This is likely to penalize patients who are honest.

The prospects for a gay man who has multiple partners of unknown HIV and treatment statuses were poorer. If he planned to continue using condoms, 86% would prescribe PrEP; if he was already not using condoms, 45% would provide PrEP; and if he planned to stop using them, just 28% would be willing to prescribe PrEP.

The differences, both between different approaches to condom use and between monogamous and non-monogamous men, were statistically significant.

The survey also asked about which reasons for discontinuing condom use were considered acceptable by the medical students. Just 13% thought it acceptable to stop using condoms to improve sexual functioning, 14% to increase pleasure, and 23% to enhance intimacy or emotional connection.

However 69% felt that discontinuing condom use for the purposes of conception would be acceptable. This suggests heterosexism, Calabrese argued. She also noted that in objectively considering the risk of acquiring HIV, the reason why a person does not use condoms is irrelevant.

Uneven Access to PrEP

Dawn Smith of the Centers for Disease Control and Prevention (CDC) said that she had asked health departments across the U.S what they were doing to support the implementation of PrEP. While the south has the highest rate of HIV diagnoses, there was much less PrEP activity there than in the west, where the needs are not as great.

Across the country, just 38% of health departments were supporting PrEP. Often, this just involved referring high-risk individuals to PrEP -- fewer health departments were actively working with healthcare providers to support PrEP delivery and even fewer were providing it themselves.

And studies from San Francisco -- the city at the forefront of PrEP roll-out -- show that women and black gay men remain less likely to be aware of PrEP and to receive itcompared to white gay men. Some services are better at engaging minority populations than others, but not all are doing enough to engage their clients on this issue.

Dominika Seidman of the University of California at San Francisco said that family planning clinics have been identified as logical and acceptable locations to reach women. Her survey of 5 family planning clinics for underserved populations in San Francisco showed that at least 7% would be eligible for PrEP under CDC guidelines, but that less than 1 in 5 of these women knew what PrEP was. Their lack of knowledge probably reflects a low awareness of PrEP among family planning providers.

Gordon said that when biomedical prevention has reached people who need it, it has given them a sense of ownership over their sexual health. "However, some communities are still not benefitting from these tools because their concerns continue to go unaddressed," he said.

He gave as examples black communities’ mistrust of the medical system and trans communities’ concerns about healthcare provider bias, drug interactions with hormones, and PrEP adherence in a context of violence and harassment. Meaningful engagement around these issues is needed, he said.

Unplanned PrEP Discontinuations

Douglas Krakower of Fenway Health in Boston presented an analysis of people who have stopped taking PrEP. Fenway is a gay-friendly provider working with an underserved population and is the largest provider of PrEP in New England. Between 2011 and 2014, 663 patients began PrEP. Krakower reviewed medical records up to the end of 2015 to see who had stopped PrEP and why.

16% of patients had stopped PrEP because they felt they were at lower risk of HIV or for another reason relating to personal choice.

However 25% had an "unplanned discontinuation" and most often this was related to insurance or financial barriers. In other cases, the person had stopped adhering to PrEP medication, had missed clinic visits, or had dropped out of care. Younger people, individuals with mental health disorders, and people with public rather than private insurance were more likely to stop taking PrEP in this way.

Krakower said that 4 patients were diagnosed with HIV after an unplanned discontinuation -- 2 had had gaps in their insurance, 1 had mental health challenges, and 1 had stopped due to stigma associated with taking PrEP.

The study suggests that support is needed to help people avoid dropping off of PrEP, including mental health support, flexible models of care delivery, support to help with adherence, and health systems navigators and patient assistance programs to help with insurance and financial challenges.

10/25/16

Sources

SK Calabrese, KH Mayer, DS Krakower, et al. The Potential for Condom Ideology to Cloud Clinical Judgment around Prescribing HIV Pre-exposure Prophylaxis (PrEP).  HIV Research for Prevention (HIVR4P 2016). Chicago, October 17-21, 2016. Abstract OA03.05.

N Gordon. A View from the Ground. HIV Research for Prevention (HIVR4P 2016). Chicago, October 17-21, 2016. Presentation PL03.02.

D Smith, G Weiss, A Kitlas, et al. PrEP Implementation by Local Health Departments in US Cities and Counties: Findings from a 2015 Assessment of Local Health Departments. HIV Research for Prevention (HIVR4P 2016). Chicago, October 17-21, 2016. Abstract OA16.03.

D Seidman, D Cipres, A Rodrigues, et al. Women‘s Knowledge of, Interest in, and Eligibility for HIV Pre-exposure Prophylaxis at Family Planning Clinics in Northern California. HIV Research for Prevention (HIVR4P 2016). Chicago, October 17-21, 2016. Abstract OA16.04.

D Krakower, K Maloney, K Levine, et al. Unplanned Discontinuations of HIV Preexposure Prophylaxis During Clinical Care. HIV Research for Prevention (HIVR4P 2016). Chicago, October 17-21, 2016. Abstract OA16.06.