According to a CDC Morbidity and Mortality Weekly Report (MMWR)(www.cdc.gov) published Nov. 27, about 25 percent of sexually active gay and bisexual adult men, 18.5 percent of adults who inject drugs, and less than 1 percent of heterosexually active adults are at substantial risk for HIV infection and should be counseled about pre-exposure prophylaxis (PrEP) to prevent infection.
The FDA approved emtricitabine/tenofovir disoproxil fumarate(www.fda.gov) (Truvada) for HIV prevention in 2012; previously, the drug had been approved for use in combination with other antiretroviral agents to treat HIV-infected individuals age 12 years or older. Taken daily, it can reduce the risk of sexually acquired HIV infection by more than 90 percent. Daily PrEP also can reduce the risk of HIV infection in IV drug users by more than 70 percent.
However, the MMWR report points to a 2015 national survey of health care professionals that found 34 percent of respondents had not heard of PrEP. The report's authors suggested that heightened awareness of the drug could lead to more physicians offering PrEP to their patients at highest risk for HIV infection and supporting these patients in their use of PrEP, thus reducing the number of new HIV infections.
"PrEP isn't reaching many people who could benefit from it, and many providers remain unaware of its promise," said CDC Director Tom Frieden, M.D., M.P.H., in a news release.(www.cdc.gov) "With about 40,000 HIV infections newly diagnosed each year in the U.S., we need to use all available prevention strategies."
- A recent CDC Morbidity and Mortality Weekly Report suggested increased awareness and use of pre-exposure prophylaxis (PrEP) could reduce the number of new HIV infections.
- The agency also recommended treating infected patients to suppress the virus, advocating for correct and consistent condom use, reducing risky behaviors, and ensuring IV drug users have access to sterile equipment.
- CDC resources specifically aimed at physicians include a 2014 clinical practice guideline on PrEP and a hotline to answer their PrEP questions.
In another MMWR report(www.cdc.gov) released Nov. 27, researchers from the New York State Department of Health reported prescriptions for PrEP for New Yorkers covered by Medicaid increased from 303 scripts filled from July 2013-June 2014 to 1,330 scripts filled from July 2014-June 2015. It's no coincidence this significant bump in the number of prescriptions filled coincided with a statewide effort to increase knowledge of the drug among potential prescribers and PrEP candidates.
Part of Bigger HIV Prevention Strategy
PrEP is just one piece of the larger HIV prevention puzzle that needs to be assembled to best combat the HIV epidemic. Additional efforts include treating infected patients to suppress the virus, advocating for correct and consistent condom use, reducing risky behaviors, and ensuring IV drug users have access to sterile equipment from a trusted source.
According to the National HIV/AIDS Prevention Strategy for the United States: Updated to 2020,(www.aids.gov) promoting full access to PrEP is one of four critical areas on which the nation must focus in the next five years.
The other focus areas are
- facilitating widespread HIV testing and linkage to care to enable early treatment for infected patients,
- providing broad support for people living with HIV to remain engaged in comprehensive care, and
- achieving universal viral suppression.
CDC Offers Resources
In March, the CDC announced(www.cdc.gov) it would award as much as $125 million in HIV prevention funding during the next three years to state and local health departments to, among other things, help accelerate the use of PrEP in men who have sex with men and transgender people at substantial risk for HIV infection.
Then in July, the CDC announced(www.cdc.gov) it plans to award $216 million during the next five years to 90 community-based organizations nationwide to assist in their HIV prevention strategies, including their efforts to expand access to PrEP.
The CDC also has published resources to educate and advise physicians about PrEP, including a 2014 clinical practice guideline(www.cdc.gov) and a supplement(www.cdc.gov) with step-by-step PrEP checklists and interview guides. The agency also supports a hotline to answer physicians' questions about PrEP.
PrEPline Provides Physicians Advice
AAFP member Ronald Goldschmidt, M.D., of San Francisco, is the director of the CDC-funded PrEPline, which provides free, expert advice to clinicians in the United States. The hotline can be reached by calling 855-448-7737 from 11 a.m. to 6 p.m. EST, Monday through Friday.
The PrEPline is manned by staff in the Department of Family & Community Medicine at the University of California, San Francisco.
"Family physicians are increasingly being requested to consider prescribing pre-exposure prophylaxis for their patients, as this important HIV prevention intervention becomes more widely implemented," Goldschmidt told AAFP News.
But he said many physicians prescribing PrEP have had limited experience prescribing antiretroviral drugs, and this is where the PrEPline can help.
"We provide guidance to clinicians as they work through decisions about who might benefit from PrEP, how to prescribe these medications and protocols for followup to ensure safe medication use averting and identifying new transmissions," Goldschmidt said. "Key to PrEP will be continually evaluating patients' ability to adhere to a daily PrEP regimen, as missed doses can negate the benefits of PrEP."
He also highlighted the important role family physicians play in increasing awareness and uptake of PrEP, because primary care physicians will likely be the clinicians who provide care to most of these uninfected patients who are at risk for HIV.
"They can discuss PrEP with their patients as an additional way of reducing risk in combination with condom use and other safe sexual and injection drug practices," Goldschmidt said.
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