Normalization of Preexposure Prophylaxis for Adolescents

The US Food and Drug Administration’s recent expansion in approval of emtricitabine/tenofovir (Truvada) for preexposure prophylaxis (PrEP) to youth who weigh more than 35 kg was a major gain for efforts to end the HIV epidemic among those aged 13 to 24 years, who accounted for 21% of all new HIV infections nationwide in 2017.¹ Nonetheless, PrEP use remains low among individuals in this age group, including those who are sexual and gender minorities (and who are among those at the highest risk of HIV acquisition).²

Many barriers could stand in the way of these adolescents adopting PrEP. Several major obstacles, we argue, emerge from the common pathway by which adolescents are expected to attain a PrEP prescription. This pathway generally involves attendance at a clinical care visit, wherein a physician assesses one’s eligibility for the medication. Eligibility, according to guidelines developed by the US Centers for Disease Control and Prevention and the US Preventive Services Task Force, is determined based on an individual’s HIV status (ie, they must have negative test results for HIV), ability to tolerate the medication (ie, they cannot have kidney insufficiency), and several other factors that signal one’s vulnerability and risk of HIV acquisition, including recent sexual risk behaviors, recent diagnosis of sexually transmitted infections (STIs), and serostatus of their sexual partners.^3,4

Ostensibly, the process of determining PrEP eligibility based on vulnerability and HIV risk in a controlled clinical environment is an efficient and safe strategy to allocate PrEP resources. However, in practice, this process can inhibit access to PrEP for many who need the medication, especially for adolescents.

Why? Because opportunities to ascertain PrEP eligibility among adolescents in a clinical setting are rare. Individuals in this age group, on average, attend preventive care appointments less than once a year, and only a fraction spend time alone during a visit with a health care professional without a parent in the room.⁵ These instances in which health care professionals can initiate private conversations with adolescent patients about the use of PrEP may be few and far between.

Moreover, in the event that such a conversation can occur, health care professionals and adolescent patients often feel considerable discomfort when discussing issues related to sexuality and sexual behaviors during clinical visits.⁶ Regardless, sexual risk behaviors remain integral to the assessment of PrEP eligibility, according to national and many local guidelines.

Beyond the difficulties in assessing eligibility, the applicability of the current guidelines in the adolescent context is also questionable. Adolescence represents a crucial period of identity formation and sexual exploration, during a time when individuals may experiment with new behaviors that are not habitual or anticipated. Younger individuals also tend to exhibit shorter and more emotionally turbulent relationships relative to their older counter-parts. Thus, recent sexual behaviors (ie, within the last 6 months) may not be a reliable indicator of impending seroconversion.

Recommendations

Adapt Eligibility Criteria to Adolescent Context

For adolescents who end up in a clinical setting, we posit that clinical guidelines should be adapted to account for the potential volatility of behaviors throughout adolescence as well as challenges in patient–clinician communication surrounding sexual behaviors. These adaptions could include (1) reducing reliance on self-report of behaviors, focusing more on indicators that could serve as proxy indicators for behaviors (eg, previous bacterial STI, recent HIV test); (2) identifying sociodemographic factors that indicate risk based on the local epidemiologic context (eg, housing instability, race/ethnicity); and (3) expanding the time for a given behavioral exposure from 6 months to 12 months or within one’s lifetime.

Alternatively, for adolescents, we might consider forgoing the assessment of self-reported sexual behaviors altogether. Such behaviors may not be best predictors of seroconversion, especially if they are unreliable or under-reported. We could then turn to objective measures of behavioral risk, such as STI and HIV testing, although we note that such measures depend on a clinicians’ initiative to order these tests and that STI and HIV testing rates remain dismally low among adolescents in the US. Dependence on these measures to assess PrEP eligibility should be paired, then, with efforts to promote widespread availability to STI and HIV testing among younger populations.

Normalize PrEP as a Tool to Promote Positive Sexual Health

The adaptations to the PrEP eligibility criteria discussed above could provide more accurate indications of HIV risk among adolescents. However, we note that risk-based assessments of PrEP eligibility could have unintended consequences: PrEP and those who use it could be further stigmatized, thus deterring PrEP adoption among many of those in need. Thus, instead of determining PrEP eligibility based on vulnerability and risk, we could consider framing PrEP in the context of health promotion. Such normalization of PrEP is a critical first step of successful PrEP scale-up for adolescents and can be done with in the context of age-appropriate sexual health education.⁷ While adolescents may not often visit clinics, they do spend a great deal of time in school and in their communities with peers. Thus, endorsing PrEP in conjunction with sexual health promotion outside of clinic settings (eg, schools, social media, dating apps) could be a useful strategy to encourage broader use of the medication. Furthermore, instead of overcomplicating PrEP initiation and management with strict criteria, we should empower adolescents to self-identify their own risk periods and practice their own prevention options that align with their specific needs (eg, for adolescents whose risk changes frequently, PrEP for seasonal exposure risk could be an appealing choice). This empowerment would necessarily involve efforts to promote accurate self-identification of risk among adolescents, who may underestimate their risk of HIV infection.

Broaden Pool of Health Care Professionals Who Prescribe PrEP

Normalization of PrEP outside of clinic settings also calls for broadening the pool of clinicians who can dispense PrEP. For example, California became the first state to allow pharmacists to dispense PrEP (60-day supply) to patients without a prescription from a physician, with the passage of Senate Bill SB 159.⁸ This option may be especially attractive to adolescents who may be hesitant to visit health care professionals in clinic settings. Furthermore, such provision of PrEP at pharmacies may also empower adolescents to initiate PrEP and practice positive sexual health.

Promote Alternative Ways to Initiate and Continue PrEP Use

Normalization of PrEP outside of clinic settings could also entail the formation of alternative ways to initiate and continue medication use. The telehealth delivery of PrEP (ie, TelePrEP), for example, can be an acceptable mechanism to increase PrEP access for adolescents. Because telehealth empowers patients to have virtual clinician visits, this treatment mechanism can alleviate some of the difficulties surrounding geographic access and social stigma. Furthermore, through the delivery of PrEP every 3 months, TelePrEP can provide support for adolescents who struggle with PrEP adherence due to challenges in attaining the medication.

Conclusions

PrEP is a breakthrough biomedical intervention for HIV prevention. For PrEP to reach adolescents, we should reframe PrEP as a health promotion and empowerment tool and move away from vulnerability and risk framework. To achieve this, we recommend the following: (1) adapt the current eligibility criteria, (2) normalize PrEP as a health promotion tool, (3) broaden the pool of clinicians who can prescribe PrEP, and (4) promote alternative ways to initiate and continue PrEP use through telehealth models.