Dear Primary Care Practitioners,
As you may know, the incidence of HIV infection in the United States has not declined in the past decade. We still diagnose about 50,000 new cases every year. This is despite incredible advances in biomedical science to treat HIV and reduce transmission, as well as increased media campaigns and educational efforts on prevention. The majority of infections remain in the gay community in men who have sex with men (MSM), but HIV still affects heterosexual individuals and those injecting drugs. Some people simply think the main missing piece is condom use. Others, like myself, parallel the HIV epidemic to unplanned pregnancies: 51 percent of all pregnancies in the United States are still unintended, and this is largely unchanged over the past ten years.
So, is the missing piece really only condom use? Is that all we have to offer our patients who are engaging in a biological act of nature but keep getting pregnant and infected with HIV?
No. The answer is LARC (long acting reversible contraception) and PrEP (pre exposure prophylaxis)—because people don’t have sex in a laboratory where condoms are always used and you know the HIV status of your partner.
PrEP is a new program to prevent HIV among those who are at ongoing risk of infection through sexual transmission and injection drug use. It has been studied for several years, after it was proven that maternal to child transmission can be reduced to less than 2 percent if the HIV positive mother and baby receive certain medications with activity against HIV. In July of 2012, the FDA approved the use of a pill for PrEP called Truvada, which is composed of two medications that treat HIV. The person at ongoing risk of acquiring HIV would take Truvada daily, see their medical provider every three months for lab tests, receive counseling for sexual health and adherence, and continue to use condoms to prevent transmission of all STIs (sexually transmitted infections) as well as clean needles for drug use. The side effects (headaches, abdominal pain, nausea, diarrhea) resolve after a few weeks in most people. With routine labwork, any issues with the medication affecting the kidneys or liver can be assessed in an adequate time frame.
If the PrEP protocol is followed by both provider and patient, and Truvada is taken every day, it can prevent transmission of HIV up to 99 percent of the time. This supersedes estimates in research trials studying prevention of HIV with condom use in heterosexuals and gay men. For those of you who prescribe statins to reduce cardiovascular risk, think about it like this: the number of people needed to treat with a statin over one year to prevent one heart attack is 250, but the number of people needed to treat with Truvada over one year to prevent one HIV infection is only 61. Doesn’t it seem crazy that you might not be using PrEP, but you hand out prescriptions for statins like candy?
Some opponents claim that giving people a pill every day to protect them against HIV will increase the amount of risky behavior like condomless sex with many partners. (Isn’t this reminiscent of people’s opinions about birth control in the 1960s?) In fact, the research studies have shown the exact opposite—subjects actually reduced their number of partners and reported more sex with condoms. PrEP and birth control don’t increase risky behavior, they just provide protection for behavior that is going to happen anyway.
You can educate yourself further on PrEP by visiting the CDC website: www.cdc.gov/hiv/prevention/research/prep.
Now that you are aware of this exciting new tool in HIV prevention, with whom should you be having this discussion? The CDC recommends considering PrEP as a viable option for the following groups of people 18 years and older:
Heterosexual men/women, trans people, or MSM who:
- have HIV positive partners
- have multiple sexual partners
- use condoms inconsistently
- have had recent bacterial STI
- exchange sex for money, food, housing, etc
- Injection drug users who :
- share injection equipment
- have HIV positive injecting partners
- have had recent drug treatment but are still injecting
In addition, focus your attention on young African American MSM ages 13-24 years old. They comprise 45 percent of new HIV infections among African American MSM and 55 percent of new HIV infections among young MSM overall. Think about your females who are not able to recommend that their male partner wear a condom. Think about your couples who want to have children where one partner is living with HIV and one is not. Think about your hepatitis C patients on methadone or Suboxone. Think about your transwomen who use injectable estrogen or engage in transactional sex.
A couple of ways to make sure that you don’t overlook these risk groups in the midst of your busy day is to a) obtain a sexual history and b) offer an HIV test. The sexual history should include the 5 Ps of sexual health: number and gender of Partners, types of sexual Practices (oral, vaginal, anal), use of Protection for STIs (condoms, etc), Past history of STIs, and Pregnancy desires and/or prevention methods. Offering an HIV test can generate a discussion of whether your patient is at risk for acquiring HIV and how they are protecting themselves. If the test is positive, you can link them to specialized care which is an effective intervention to reduce HIV incidence in the community. If the test is negative, you can hand them a pamphlet from the CDC website about PrEP and recommend that they review the information. At your next visit, you can both have an informed discussion about whether PrEP is something they feel empowered to use to remain HIV negative.
Everything in medicine comes down to making decisions based on risk and benefit. As a nurse practitioner, I leave my morals and judgment at the door when I see my patients. For whatever reason, if I find that they are at risk of contracting HIV, or if they are worried about it, we have a conversation about PrEP as an evidence-based option.
Please consider educating yourself and your patients about PrEP. Let’s prevent heart attacks, unintended pregnancies, and HIV. In my mind, one is no more important than another, and our patients deserve to benefit from modern medicine delivered by progressive front line primary care providers.