HIV Preexposure Prophylaxis

In their excellent brief article, Marcus et al. have compared “the proportion of PrEP [preexposure prophylaxis] users and non-PrEP users receiving primary care”^1(p1418) and contend that PrEP, in addition to being an effective HIV prevention strategy, has the added advantage of acting as a gateway to primary care. Although this is true, the effectiveness of PrEP depends primarily on the number and rate of prescriptions. In that context, this article is more important in drawing attention to the limitations associated with prescription of PrEP (and other services) to qualified candidates. Thus, out of 5857 HIV-negative individuals tested for rectal sexually transmitted infections—who are excellent candidates for PrEP—only 2047 (35%) were prescribed PrEP. The important question is why the others were not prescribed PrEP (although some may have had counterindications that were not indicated in the article). In addition, all these patients, not only PrEP users, should have received influenza vaccination, tobacco screening, depression screening, and glucose testing.

The effectiveness of PrEP is well established^2,3; however, for PrEP to be effective, it must be prescribed in the first place. It is well documented that most health care providers are untrained in PrEP provision.⁴ It is in that context that this article is important; as the authors rightly note, “because of the dedication of Fenway Health to providing primary care to sexual and gender minorities, the associations we observed between PrEP use and primary care may overestimate those at other community health centers that do not have the same mission.”^1(p1419) Thus, if Fenway Health prescribes PrEP to only 35% of eligible candidates, other providers may be prescribing less, and this has a negative impact on HIV prevention overall. Treatment as Prevention (TasP) is well accepted and established.⁵ PrEP is the other side of the prevention coin, the turn of phrase - Prevention as Treatment (PasT) as in preventing a negative person from getting HIV by treating with PrEP). Reluctance to prescribe PrEP may be related to the novelty of the concept and hesitation to adopt a new practice.

As Blackstock et al. have succinctly and accurately stated, “Health care providers play a central role in the implementation of new health-related technologies, given their access to individuals or populations that might benefit most. Primary care physicians (PCPs), in particular, are optimally positioned to provide PrEP, given their focus on health promotion, disease prevention, and longitudinal care. Additionally, PCPs primarily deliver care to HIV-negative individuals, some of whom may be at substantial HIV risk, and therefore PrEP eligible.”^6(p62)

Noting that 93% of providers were aware of PrEP but only 34.9% adopted it, they recommend that primary care physicians without HIV care experience should be targeted and those with HIV care experience must be trained to be PrEP “clinical champions.” More recently, it has been documented that there has been increasing awareness, familiarity, and comfort in prescribing PrEP among primary care providers.⁷ On the basis of these findings, I argue that there must be more serious consideration and discussion on the need to prescribe PrEP and PrEP training, including among primary care physicians, if we are to be successful in preventing HIV in the United States.