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As of July 2022, pre-exposure prophylaxis, or PrEP, has been available for a decade in the United States.
With up to a 99 percent success rate, one would think that the United States is well on its way to meeting its goal of eliminating new HIV infections by 2030 and ending the epidemic. But the success of PrEP has been muted by an ongoing problem: insufficient adoption. According to some sources, less than a quarter of people who could benefit from PrEP are taking it.
PrEP adoption appears to vary across racial and ethnic lines. Of those who are on PrEP, 42 percent are White, 31 percent are Hispanic, and 27 percent are Black.
Barriers to PrEP adoption
There are significant and persistent barriers to access and adoption of PrEP. These include stigma, lack of patient knowledge, and insufficient physician education – including misconceptions about who and what PrEP is for.
Unfortunately, stigma continues to surround HIV and the use of PrEP. There’s a misconception that, as opposed to trying to protect themselves and others, PrEP users are irresponsible or promiscuous.
Misunderstanding among the potential patient community can fuel that stigma, making it a persistent barrier. Some prospective users may also perceive that frequent HIV testing is a less expensive alternative to PrEP
Insufficient physician education is another barrier to the use of PrEP. While health care providers can play a key role in providing patient education, increasing awareness, and helping to reduce stigma, they may need additional training to play this role effectively. Although many if not most primary care providers are aware of HIV PrEP, fewer than one in five physicians has ever prescribed it.
Dismantling the barriers
Significant steps have been taken to remove cost as a barrier to PrEP, which must be available free of charge under almost all health insurance plans as legislated by the Affordable Care Act.
There are ways to encourage more widespread adoption of HIV PrEP by dismantling the other barriers, including educating patients and providers, increasing access, and combating stigma by normalizing PrEP.
Experts in the space recommend greater integration of PrEP within health care,
Education is critical to equipping primary care providers with the information they need to adopt HIV risk assessment as a standard of care and improve their ability to identify PrEP candidates. Beginning this education in medical school would prepare new primary care providers to encourage PrEP adoption from the beginning of their careers.
Partnering with patient advocacy groups could potentially facilitate these education efforts.
Retail pharmacies can play a key role in making PrEP accessible to more people. In some states including California, Colorado, and Oregon, pharmacists can prescribe PrEP for patients with a negative HIV test and baseline testing for sexually transmitted infections. Most state laws limit pharmacist-prescribed PrEP to a 60- or 90-day supply.
However, for patients for whom geography or transportation present barriers, there are solutions in the form of virtual care and new types of therapy. At one point, two rural counties had the highest county-level HIV infection rates in the country.
Apretude, the recently approved long-acting injectable, can improve access to care for members in rural areas or with transportation challenges. It requires a provider visit only every other month and eliminates the burden of taking a daily pill.
Addressing stigma around PrEP is critical to increasing adoption. The health care community can combat stigma by normalizing PrEP. Working with thought leaders, advocates, and government agencies, we can spread and reinforce the message that HIV prevention works.
Virtual PrEP Care
Solving for stigma, geography, and transportation, virtual models help improve access to care while reducing costs for plan sponsors.
Increasing PrEP adoption among populations is critical. The nation’s health care system could save the lives of tens of thousands of individuals as well as avoid estimated lifetime HIV-related medical costs averaging $400,000 per patient.