Although it's widely accepted as an effective means of lowering the chances of HIV infection in high-risk individuals, preexposure prophylaxis (PrEP) is used by just a fraction of the estimated 1.2 million people for whom it's indicated (see What Is PrEP?). Though PrEP use has increased annually since its introduction to the market in 2012, its underuse is of concern to infectious diseases experts, public health officials, and HIV prevention advocates who view PrEP as a crucial tool for reducing new HIV infections. As a letter to the editor in the May-June 2015 Journal of the Association of Nurses in AIDS Care noted:
"PrEP can prevent a serious illness that occurs primarily in sexual and racial minorities, and in poor and disenfranchised populations, populations for whom we feel we have a moral obligation to advocate for full access to equitable health information and state-of-the-art HIV prevention and treatment."
In 2014, the Centers for Disease Control and Prevention released the first comprehensive clinical practice guideline for PrEP use. Since then, researchers have suggested several explanations for underuse of the antiretroviral medication. Chief among them are stigma, misconceptions, and prescribing clinicians' lack of knowledge about the drug.
"Everything about HIV has changed; it's easier to manage than diabetes," says Mary Goodspeed, BS, RN, coordinator of HIV clinical education at Erie County Medical Center in Buffalo, New York. "What hasn't changed is stigma, fear, and discrimination." Goodspeed believes there's no reason not to prescribe PrEP to patients at high risk for HIV infection. Although financial challenges exist, PrEP is covered by most commercial insurance plans and by Medicare; Medicaid coverage varies from state to state. For the uninsured, there's a patient assistance program offered by the manufacturer, and drug assistance programs are available in some states, including New York, Massachusetts, and Washington.
Nevertheless, primary care providers frequently refer inquiring patients to infectious disease specialists or HIV or sexually transmitted infection (STI) clinics, missing opportunities to address PrEP themselves. Providers may feel they are not knowledgeable enough about HIV and high-risk populations to prescribe PrEP. This is particularly true for providers who are unfamiliar with the lesbian, gay, bisexual, transgender, and questioning (LGBTQ) community and for many pediatricians who care for adolescents-a population that is not traditionally considered at risk for HIV infection.
Many primary care providers are also reluctant to include sexual health in patient assessments because either they are uncomfortable or they lack the time needed to provide risk-reduction counseling. In addition, some providers are concerned that using PrEP may increase patients' sexual risk behavior, putting them at higher risk for other STIs. This, says Lyn C. Stevens, MS, NP, ACRN, deputy director of the Office of the Medical Director, New York State Department of Health AIDS Institute, is reminiscent of the decades-old myth that using oral contraceptives leads to promiscuity. In fact, studies by Marcus and colleagues in PLoS One (2013) and Fonner and colleagues in AIDS (2016) suggest that sexual risk compensation is not a consequence of PrEP use. This alone may be enough ammunition for nurses to advocate for increased PrEP access among their prescriber colleagues.
Stevens says nurses should take the initiative to discuss sexual health with patients during routine visits, and especially when patients come in for STI or HIV testing. She notes that conversations about PrEP should be held with those whose assessments indicate high HIV risk. "Educating patients is key for every nurse," she says.
Like some clinicians, many patients, including those in the highest-risk groups, are also reluctant to talk about sex or PrEP in the primary care setting. They may fear judgment or stigmatization from their physician. In contrast, in practices in which sexual discussions are not taboo, such as those in which clinicians are familiar with LGBTQ communities or specialize in treating HIV or infectious diseases, patients often have closer relationships with their physician and are often the initiators of sexual health and PrEP discussions.
EDUCATING THE EDUCATORS
Clearly, education is key to addressing the barriers to PrEP prescribing. "Once patients hear about [PrEP] and try to access it, they call an office and the first person they talk to is a nurse," says Stevens. "Nurses should be able to answer questions, counsel patients about options, and refer them to community services." This is important because PrEP alone isn't a magic bullet: it's part of a broader HIV prevention strategy that requires support services; medication adherence; safer sex practices; compliance with quarterly laboratory testing; emotional support; help with insurance; and, for some patients, social services including transportation, food assistance, and housing.
As nurses, Goodspeed and Stevens have played instrumental roles in working to address barriers to PrEP prescribing and to further New York State's aggressive agenda in PrEP policies and infrastructure. Both are active in community and clinical outreach, but place special emphasis on educating nursing school faculty (and faculty of other health professions) and keeping them and their students up to date. It hasn't been easy. Stevens says that in her 30 years of working to mainstream education on HIV prevention and treatment, she's been told that curricula are "too full" to accommodate the topic. But Stevens's and Goodspeed's work at local, regional, and state levels continues, and they urge all nurses to get similarly involved in their communities and schools, particularly in rural and other areas with underserved, marginalized groups.-Sibyl Wilmont, MPH, MSN, RN