Three Potential Barriers to HIV PrEP

Several barriers prevent many health care providers from prescribing pre-exposure prophylaxis (PrEP) to patients at high risk for HIV.

Consistent PrEP use can lower the risk of HIV infection by 92% among those at high risk for transmission, according to the US Centers for Disease Control and Prevention (CDC).

The CDC recently released a fact sheet describing how 25% of sexually active gay and bisexual men, 20% of individuals who inject drugs, and 1 in 200 sexually active heterosexual adults should be offered PrEP.

Grindr for Equality—the men’s health advocacy arm of Grindr, the world’s largest gay social network—conducted a survey ahead of World AIDS Day to measure users’ understanding of the availability of Truvada as PrEP.

The poll followed an American Academy of HIV Medicine (AAHIVM) survey of 324 regional HIV care providers on their PrEP prescribing habits.

Both the AAHIVM survey and Grindr poll revealed the following barriers to HIV PrEP:

1. PrEP Adherence

According to the Grindr poll, 35.2% of those who are not currently taking PrEP but have expressed an interest in doing so report feeling anxious about having to take the pill consistently each day. However, 90% of respondents currently on PrEP reported taking all 7 doses for the past week.

Despite the generally positive numbers associated with PrEP adherence, health care providers still cite adherence as a reason for their hesitation to prescribe the drug. Other provider concerns include follow-up care for monitoring and counseling PrEP patients, as well as the therapy’s overall efficacy in preventing HIV.

The AAHIVM survey revealed that less than half of providers would be “very likely” to prescribe PrEP to IV drug users, heterosexuals with HIV risk factors, methamphetamine users, and gay men with an HIV-positive partner on highly active antiretroviral therapy.

“Providers’ reticence to prescribe to these groups may reflect beliefs about transmission risk behavior or concerns about the efficacy of PrEP for heterosexual patients,” the survey authors wrote.

Pharmacists should always encourage all patients to stay adherent to their medications, but with respect to PrEP, they can let patients know about the CDC estimate that the regimen, if correctly adhered to, can reduce their risk of HIV by 92%.

“Pharmacists can be first-line providers in providing information…and can play a role at each stage of the HIV [prevention] and care continuum,” Jacek Skarbinski, MD, of the CDC previously told Pharmacy Times.

2. PrEP Access

The vast majority of Grindr poll respondents who are currently taking PrEP therapy (91.2%) said they access it through their health insurance. Only 1.9% said they do not have insurance.

Nevertheless, finances and insurance remain important access concerns among those who are not currently taking PrEP but desire to do so. In the Grindr poll, 16.8% of these patients cited a lack of health insurance as their reason for not taking PrEP, and 13% of those not currently taking PrEP say they have insurance but it won’t cover the therapy.

Among those who are not interested in taking PrEP, 19.3% said issues of finance and insurance contributed to their disinterest.

With respect to geography, the Grindr poll found that rural respondents “faced a variety of increased hurdles to accessing PrEP, notably including lack of access to LGBT-competent doctors and community clinics.” Race also played a role in lack of access to PrEP therapy.

Although 10% of poll respondents reported difficulty with getting their physicians to prescribe Truvada for them, the likelihood of this scenario was doubled for black men. Among the group of respondent black men interested in PrEP, 5.7% said their doctor refused to prescribe it.

Grindr surmised that language barriers could also be causing PrEP access issues. Latinos reported low levels of PrEP usage, and Grindr stated on its blog that it plans to address this by “prioritize[ing] the circulation of PrEP information in Spanish.”

Difficulty with accessing Truvada could lead some patients to turn to illegal pharmacy websites that sell unapproved prescription drugs and devices—including Truvada. These pharmacies may not only be selling dangerous products, but also be involved in credit card fraud and identity theft.

For these reasons, community and health-system pharmacists should take the time to explain to at-risk patients how access to Truvada can be improved and sustained.

3. PrEP Education

The Grindr poll found that respondents wanted more information about PrEP therapy, and patient education is perhaps the most valuable thing pharmacists can provide.

More than half of poll respondents who aren’t currently taking Truvada but want to said they don’t know much about it, while 37.3% of those not interested in taking it at all said a lack of information contributed to their disinterest.

On the provider side, a recent CDC report revealed that one-third of primary health care physicians and nurses don’t know anything about Truvada.

The findings of the AAHIVM survey “emphasize that health care providers need ongoing education and guidance about how to deal with practical issues associated with prescribing PrEP,” said lead author Leah M. Adams, PhD, a research fellow at Group Health Research Institute, in a press release.

The Grindr poll revealed that there is some concern among respondents over immediate side effects, but “there is much more anxiety about PrEP being new and the possibility of facing long-term side effects or unknowns in the future.”

Based on recent studies, pharmacists can reassure patients that taking PrEP does not increase their risk for depression.