Unmet need for HIV PrEP therapy
Ryan Haumschild, PharmD, MS, MBA: Carl, which groups of eligible patients are most likely to see PrEP [pre-exposure prophylaxis] therapy in your experience? We heard Frank and Ryan mention one of the drivers of use, of expanding use, but which groups are most likely to receive PrEP, and then which are the least likely to receive PrEP? PrEP therapy? Thinking of the social determinants of inclusion, equity and diversity in health, perhaps include this when we talk about this expansion of use.
Carl Schmid: Sure. CDC [Centers for Disease Control and Prevention] did a test a few years ago, and they said there are about 1.2 million people who are probably eligible for PrEP. Maybe that number has increased, but based on that number, they are currently looking at the use of PrEP. As Ryan said earlier, for white males it’s higher; 61% of eligible people are part of it. Now we want 100%, so it can still grow. But where we see a lack of PrEP uptake is among Hispanics; they are only 14.6% of those who are eligible. And much, much lower are Blacks and African Americans, just 8.4%. It is also very low for women, only 9.6% of those who are eligible for PrEP take it. If we look at the age groups, below 24, it is only around 14%. We need to increase the use of PrEP. If you also look at the geographies, you look at New York State, that’s over 40% of eligible people. But if you look at Alabama, it’s only 16 or 17%.
There is a lack of education. There is still a lot of stigma associated with it. People do not have access to health care, especially in the southern states, due to the lack of expansion of Medicaid, so there is a lot of work to be done.
Ryan Haumschild, PharmD, MS, MBA: It’s interesting that you talk about it because we are starting to expand education, policies to create access to these drugs. But how many people are still underserved and just don’t understand that this is out there, its effectiveness? Or they say, “Hey, I’m a young man. I feel like I’m in good health. Why should I take and comply with medication every day? Do you see that too, when you talked about some demographic information? Is this also a factor that perhaps explains why there are certain barriers to therapy?
Carl Schmid: Yes, exactly what you said. Why would anyone want to take medicine, “if I’m not sick?” I feel good. ”They don’t always realize that they are at risk for HIV, so it’s our job to do is educate people. Especially in the south, black gay men. , Latino homosexual men, but also black women, also need to be educated, as well as their providers.
Ryan Haumschild, PharmD, MS, MBA: Well, that’s another thing. I want to move on, but I’m curious, how often do providers get enough education in this space? Because we have so many patients who are seen in primary care clinics, where someone may not be diagnosed, and how attentive are we to looking at some of these risk factors, to some of these questions and to the screening processes to make sure we’re more proactive? And do we make sure to identify the most suitable people for therapy, providing them with effective education? Carl, that’s one thing that really stood out to me in what you said, if people don’t know or if we don’t provide education for them, or if they fear that they are in good health and that there’s nothing else to add, then maybe they won’t see the need for follow-up because we’re thinking about joining and taking things, that’s important. Adherence is an important part of PrEP therapy, but if people don’t get the right education about it, don’t have the right adherence, or don’t understand the importance of it, they will bypass it. , and even if they know it, don’t take it. I don’t know if anyone else has seen this in their practice. Frank, I know you are an active practitioner, do you see some of it, and is this an unmet need as we start to look at expanding the use of PrEP?
Frank J. Palella, MD: Absoutely. Awareness is the first step in accepting and adopting the use of PrEP. Awareness is the problem for many untreated, or non-prophylactic so to speak, people who are eligible for PrEP. This is especially true among young MSM [men who have sex with men], as well as young women who would be eligible living in an area of higher prevalence. It also tends to demographically and disproportionately influence people of color. I will comment once again that all this youth syndrome is a barrier to adopting preventive health practices. Instead of being sensitive to a diagnosis, the diagnosis here is risk. Diagnosis is a risk for HIV, and taking daily medications of any kind requires going through a psychological portal of self-recognition that such a risk exists.
Adoption of PrEP in young people has been compared to juvenile diabetics who feel well and cannot believe that anything could threaten them, nor the need for daily insulin therapy. The added challenge here is that it is very difficult for anyone, let alone young people, to think of something as pleasantly acquired as through sex, which can pose a risk to them. “How could sex be bad for me, or how could sex be risky?” The strategy of positively presenting PrEP as a step that will improve the safety and enjoyment of worry-free sex has been adopted in many cities, including the New York City Department of Public Health.
Ryan Haumschild, PharmD, MS, MBA: Frank, a question for you then is, PrEP has been somewhat revolutionary in the benefits it provides. But do you still see an unmet need, and is that unmet need more about educating and identifying people, or do you think PrEP is the answer? How does PrEP fit into the unmet needs still in this space?
Frank J. Palella, MD: PrEP is one of the global STDs [sexually transmitted disease] prevention, which passes, once again, through the clinical cascade of care that we have adopted with HIV. Screening, referral to therapy, initiation of medication, in the case of HIV, obtaining an undetectable viral load, then retention and treatment. In the case of PrEP, it is about identifying the risk, testing and making sure that someone is not infected with HIV, as this is a prerequisite for initiation. of PrEP, starting the drug, then monitoring people. Ideally, follow-up is done every 3 months, at which time screening for syphilis, gonorrhea, chlamydia and, if applicable, other STDs such as viral hepatitis, herpes, warts, also takes place.
PrEP is an important facet of a comprehensive STD prevention strategy. It should not be viewed simply as providing a prescription for a daily pill that can prevent HIV, but as one of the first steps in building a relationship to keep an individual free from HIV and STDs. . This includes counseling, the provision of condoms, a health care environment in which people feel comfortable disclosing the most intimate details of their lives. And it requires that providers feel comfortable talking about it easily in the language surrounding PrEP, easy in the follow-up that needs to take place when people are introduced to PrEP, and available to answer questions and be a confidant.
Ryan Haumschild, PharmD, MS, MBA: I love your passion. Obviously you are very excited about this and I love your holistic approach, where PrEP is probably a key factor in ending this epidemic initiative. But like you said, there are other tests, other education programs, and other safe sex practices that we need to build into PrEP therapy to be successful. You did a great job of summing it up. I know a lot of our payers and providers are looking at this, and they’re going to ask, what can we do as part of a holistic approach? Realize that PrEP alone is great, but comes with education and many enveloping support services that are individualized for each of these patients. So, great context there. I appreciate that.
Transcription edited for clarity