We appreciate the opportunity to respond to the letter by Fernando in reference to our study, and we share his concerns about limited uptake of HIV preexposure prophylaxis (PrEP) in populations at risk for HIV acquisition.
The goal of our study was to explore the relationship between PrEP use and receipt of routinely recommended primary care. Our study population was patients who were tested for rectal sexually transmitted infections, suggesting recent condomless anal intercourse and eligibility for PrEP. Fernando raises the important question of why many of these patients were not prescribed PrEP. Although some may have had contraindications to PrEP use or preferred other HIV prevention methods, we agree with Fernando that there is ample room for improvement in PrEP uptake.
The Centers for Disease Control and Prevention estimate that 1.1 million individuals in the United States have indications for PrEP use,1 yet national pharmacy data suggest that only 100 000 people used PrEP in 2017, with substantial demographic and geographic disparities in uptake.2,3 Multiple barriers to PrEP use exist among individuals at risk for HIV acquisition, including cost, perceived low risk of HIV acquisition, stigma, and medical or pharmaceutical mistrust.4 Barriers also exist among providers, including lack of familiarity with PrEP, inadequate training in HIV risk assessments, and concerns about potential risk compensation among PrEP users.5 Many of these barriers were likely minimized in our community health center, which specializes in care for sexual and gender minorities by providers who are familiar with conducting HIV risk assessments and prescribing PrEP; nevertheless, uptake was low.
Efforts are urgently needed to mitigate barriers to PrEP use if the population-level benefits of PrEP are to be realized. Examples from our own work include outreach to facilitate PrEP uptake among patients with recent diagnoses of rectal sexually transmitted infections or syphilis6 and automated algorithms that integrate electronic health records data to help providers identify patients who may benefit from PrEP.7
In addition to its potential effect on the HIV epidemic, PrEP may influence other key health outcomes. Our study on PrEP use and health care use suggested that by engaging patients in primary care, the benefits of PrEP may extend beyond HIV prevention to other areas of health, including behavioral health and prevention and treatment of other infectious and chronic diseases. As interventions to increase PrEP uptake are evaluated and implemented, it will be critical to monitor their effect on not only HIV incidence but also broader health outcomes.
ACKNOWLEDGMENTS
This work was supported by the National Institute of Allergy and Infectious Diseases (K01 AI122853 to J. L. Marcus) and the National Institute of Mental Health (K23 MH098795 to D. S. Krakower).
J. L. Marcus has received research grant support outside the submitted work from Merck. D. S. Krakower has conducted research with project support from Gilead Sciences; has received honoraria for authoring or presenting continuing medical education content for Medscape, MED-IQ, DKBMed, and Uptodate, Inc.; and has received royalties for authoring content for Uptodate, Inc. K. H. Mayer has received unrestricted scientific grants from Gilead Sciences and Viiv Healthcare.
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