Only four in 10 gay and bisexual men in Baltimore without HIV are aware that pre-exposure prophylaxis medication (PrEP) may significantly reduce their risk of contracting the virus, even those who had recently visited a doctor or been tested for a sexually transmitted disease, new Johns Hopkins Bloomberg School of Public Health research suggests.
Studies have shown that PrEP, a once-daily pill, reduces HIV incidence by 92 percent in HIV-negative people who are at high risk for HIV, including men who have unprotected sex with men, and it is recommended for that group by the Centers for Disease Control and Prevention. In 2011, HIV incidence among gay and bisexual men nationally was 18 percent; in Baltimore, it is estimated to be 31 percent. Still, since the U.S. Food and Drug Administration approved PrEP in 2012, only five percent of high-risk individuals have taken it for HIV prevention.
The new findings, published online in the American Journal of Preventive Medicine, suggest that many health care providers don't even discuss PrEP, even with high-risk patients they know are gay or bisexual or have been tested for other sexually transmitted diseases. The Centers for Disease Control and Prevention says that as many as one-third of physicians may not even know PrEP is an option.
"Doctors have limited time with their patients, but with gay and bisexual male patients, physicians definitely need to make it a point to discuss HIV risks and whether PrEP is a good option," says study leader Julia R.G. Raifman, ScD, a post-doctoral fellow in the Bloomberg School's Department of Epidemiology. "Health care providers may be unfamiliar with PrEP or may be uncomfortable broaching sexual health topics with their patients. Whatever the reason, we need to find a way to get PrEP to the people who can most benefit. PrEP could be a game-changer for HIV in the United States where there are more than 44,000 new cases of HIV every year - but only if people know about it."
When people are diagnosed with HIV, they are typically given a three-drug regimen to combat the virus. PrEP is made up of two of those medications combined into a single pill to take once a day. The side effects are generally mild.
For the study, the researchers used the 2014 Baltimore MSM National HIV Behavioral Surveillance data. There were 401 HIV-negative participants in the study, of whom 168 (42 percent) were aware of PrEP. Interestingly, having seen a doctor (82 percent had) and having a test for another sexually transmitted disease (46 percent had) in the prior year did not increase the likelihood that a gay or bisexual man knew about PrEP. Those who had been tested for HIV in the prior year were more likely to be aware of PrEP.
Once study participants were told about PrEP, which has been likened to a birth control pill taken daily to prevent an unwanted outcome, 60 percent said they would be willing to take PrEP for HIV prevention.
The researchers also found that twice as many black participants as white participants in the study were unaware of PrEP. Raifman says that is troubling since statistics suggest that one of every two gay black men will get HIV in their lifetimes.
While PrEP can be a lifesaver, there are still barriers to its wide use. The medication is expensive, though educated doctors could direct patients to programs that fully or partially cover the costs of PrEP. People who take PrEP also need to visit a doctor for monitoring every three months, which can be a challenge for some.
Educating doctors and patients will be a key to expanding the use of PrEP. "A lot of providers who remember the early days of the AIDS crisis, when high doses of AZT caused horrible side effects, may be intimidated by PrEP," Raifman says. "The most common symptoms of PrEP are mild nausea and fatigue, which usually go away after the first month. Physicians may not understand that PrEP is nothing like the high doses of AZT initially used to treat HIV."
Raifman says a full-scale physician education program is needed, including educating primary care doctors at conferences and meetings, publishing in journals that target primary care doctors and designing guidelines and interventions to improve awareness and encourage appropriate use of PrEP.
"This is a new safe and effective tool in our toolbox to prevent HIV," Raifman says. "But it does us no good if no one is using it."
"Healthcare Provider Contact and Pre-exposure Prophylaxis in Baltimore Men Who Have Sex With Men" was written by Julia R.G. Raifman, ScD, Colin Flynn, ScM, and Danielle German, PhD.
The National HIV Behavioral Surveillance System (NHBS) is funded by the CDC. Baltimore activities are funded through a cooperative agreement with the Maryland Department of Health and Mental Hygiene. The study was also supported by the National Institutes of Health's National Institute of Allergy and Infectious Diseases (T32AI102623 and P30AI094189) and National Institute of Mental Health (7R25MH083620-07).