Pre-exposure prophylaxis and primary care

INTRODUCTION

Despite the increasing evidence of the effectiveness of pre-exposure prophylaxis (PrEP) as a HIV prevention strategy, its usefulness is rarely reported in the general practice literature.¹

HIV infection remains a major public health concern worldwide and it is men who have sex with men (MSM) that carry a disproportionate amount of the disease burden.² Despite evidence that the rate of new HIV infections in the UK is falling, the rate among young MSM is a cause for concern.² The Republic of Ireland (ROI) has not seen a similar decline, with 523 new HIV cases diagnosed in Ireland in 2018.³ Similar to other European countries, the main risk for HIV transmission in Ireland is sex among men.^2,3

HEALTH DISPARITIES AND MINORITY STRESS

With the recent introduction of legislation allowing same sex marriage in both the UK and Ireland, there is increasing acceptance of LGBT people; however, many LGBT people continue to experience stigma and discrimination.⁴

It is recognised that LGBT people experience inequalities across a range of health issues when compared to heterosexuals; including higher levels of anxiety, depression, self-harm, suicide, and drug dependence.⁴ Minority stress may explain some of these identified disparities,⁵ and this theory has also been proposed as an explanation for the high levels of risk-taking behaviour seen in MSM populations.⁵ Marginalisation and stigma are certainly recognised as factors that contribute to people engaging in risky behaviour.⁵

A COMPREHENSIVE APPROACH TO HIV PREVENTION

A wide range of HIV prevention initiatives aimed at MSM have been taking place for many years, including: HIV testing, STI testing and treatment, condom provision, education around sexual behaviour, alcohol and substance misuse, PrEP, and treatment as prevention.⁶ These programmes have been introduced at a challenging time, with increasing levels of sexualised drug use among MSM facilitated by the internet and smartphone applications.^7,8 Ongoing HIV-related stigma also impacts negatively on the success of these prevention programmes.⁶

Alternative HIV prevention approaches are needed, and PrEP is a promising option. PrEP involves people who are HIV negative taking oral antiretrovirals (most commonly a combination of tenofovir and emtricitabine) to prevent infection. PrEP has been demonstrated to be highly efficacious among MSM.⁹ PrEP should be provided along with holistic assessment, frequent testing for HIV and other STIs, advice on safer sex practices, and medication adherence support and counselling for individuals at substantial risk of infection.

PRE-EXPOSURE PROPHYLAXIS IN IRELAND AND THE UK

Both in the ROI and UK, Health Technology Assessments (HTAs) have shown that the provision of PrEP is cost effective and has the potential to prevent a significant number of new HIV infections.^10,11

PrEP is now available in healthcare settings across the ROI and the UK. In the UK, PrEP is provided on a trial or pilot basis and through sexual health clinics. Since November 2019, the ROI has begun the roll out of a national PrEP programme. In addition, it is recognised that there are significant numbers of MSM self-sourcing PrEP in both jurisdictions.¹

The Irish programme does not specifically exclude general practices from providing PrEP, but to date, it is only being provided at specialist sexual health clinics. The UK PrEP programmes specifically exclude routine primary care.

The Irish HTA reported concerns regarding ‘existing capacity constraints, staffing and infrastructural issues of public STI services’, and advised that, ‘significant investment in the broader service may be necessary to support the provision of a safe, sustainable and equitable PrEP programme’.¹⁰

‘PrEP GAP’

This ‘PrEP gap’ is the level of unmet need that exists for PrEP. It is recommended that PrEP be integrated into existing HIV prevention programmes targeting those most at risk of HIV infection.¹² The Joint United Nations Programme on HIV/AIDS (UNAIDS) has set a global target that 3 million people would have access to PrEP by 2020. Despite this, over 500 000 MSM in the EU who would be likely to use PrEP do not yet have access to it.¹² A recent study among Irish MSM reports a significant PrEP gap.¹³ The longer the delay in access to PrEP for these men, the higher the likelihood that more HIV infections will occur. PrEP’s potential to eliminate HIV is currently unrealised by national healthcare systems. In order to accelerate progress towards ending the AIDS epidemic by 2030, a much wider implementation of PrEP services will be required, including its expansion into routine primary care.

SEXUAL ORIENTATION DISCLOSURE

Many LGBT people do not disclose their sexual orientation to healthcare professionals.¹⁴ This failure is associated with the fear of a negative reaction and can have an impact on LGBT people accessing appropriate and timely healthcare. GPs are well placed to facilitate disclosure and reduce associated stigma.^1,14

GP surgeries should be safe places at which patients can discuss sexual orientation, with GPs’ communication skills (both verbal and non-verbal) facilitating this by being accepting and inclusive.¹⁴ GPs are well placed to manage the other identified healthcare needs of LGBT patients, including mental health and drug dependency, which are rarely managed in STI services.¹ The provision of PrEP in primary care has the added benefit of improving general healthcare uptake by MSM, which in the long term could reduce the identified health inequalities experienced by this population.¹⁵

Provision of STI screening services for all patients at primary care level is underdeveloped.¹⁰ Primary care in Ireland is neither resourced nor encouraged to expand STI screening services. Sexual health care for MSM is often seen as a specialist area, and GPs are recommended to refer to specialist sexual health clinics. Many GPs are well equipped to manage the complexity of STI management in MSM.

Expanding sexual services into primary care settings has the potential to reduce stigma and improve access to STI screening and PrEP, and to engage many more MSM in HIV prevention.¹⁵ Up to now, public health efforts to engage high-risk MSM in HIV prevention has been a struggle and has had limited success.⁶ It is now timely to shift the focus and support routine primary care as a key location to engage this at-risk group.

CONCLUSION AND RECOMMENDATIONS

Policy makers and healthcare funders in the UK and Ireland are failing to recognise the potential of primary care services, including general practice, to deliver this effective HIV prevention strategy. Sláintecare, Ireland’s 10-year health policy, has the stated aim of ‘deliver a universal health service that offers the right care, in the right place, at the right time, with a priority focus on developing primary and community services within a national policy context’,¹⁶ and the provision of PrEP in primary care settings would really support that.

In the UK and Ireland, primary care services are ideal locations to implement PrEP services delivered within a broader HIV prevention framework, and so they should be supported to maximise this potential. At the same time, medical schools and GP training schemes must ensure that there is work done on education around LGBT health care. If this is done, then our national health services, and especially general practice, will begin to address the issues of minority stress and stigma, which impacts so negatively on LGBT health and HIV prevention strategies among MSM.

Provenance

Freely submitted; externally peer reviewed.