Challenges in PrEP Access, Long-Acting PrEP
In this roundtable discussion, Jeffrey Kwong, DNP, MPH, ANP-BC, interviews John J. Faragon, PharmD, BCPS, BCGP, AAHIVP, Damon Jacobs, Rasheeta Chandler, PhD, RN, FNP-BC, Jonathan Appelbaum, MD, and Princy N. Kumar, MD, about HIV prevention, including use in Black women, challenges of pre-exposure prophylaxis (PrEP) uptake, ways to address barriers to PrEP, the use of cabotegravir, and possible adverse effects of oral PrEP and long-acting injectables.
Additional Resources:
- Krakower D, Marcus JL. Free the PrEP - over-the-counter access to HIV preexposure prophylaxis. N Engl J Med. 2023;389(6):481-483. doi:10.1056/NEJMp2305644
- HIV Nexus Clinician Resources. Centers for Disease Control and Prevention. Updated March 6, 2023. Accessed October 26, 2023. https://www.cdc.gov/hiv/clinicians/index.html
- National Clinician Consultation Center. Target HIV. Accessed October 26, 2023. https://targethiv.org/ta-org/clinician-consultation-center
For more HIV prevention content, visit the disease state hub.
TRANSCRIPTION:
Jeffrey Kwong, DNP, MPH, ANP-BC:
Hello everyone and welcome to Consultant 360's multidisciplinary round-table discussion on HIV prevention. Today we'll be discussing health disparities, PrEP access, and the use of long-acting PrEP as a choice to increase access.
I'm Jeffrey Kwong. I'm a nurse practitioner and professor in the division of Advanced Nursing Practice at Rutgers School of Nursing in Newark, New Jersey, and a practicing clinician at Gotham Medical Group in New York City. I'll be serving as your moderator for this episode.
Joining me today are several esteemed colleagues in the field of HIV prevention. Dr. Rasheeta Chandler is a nurse researcher and family nurse practitioner. She currently is an associate professor at Emory University's Nell Hodgson Woodruff School of Nursing in Atlanta, Georgia. Dr. Princy Kumar is an infectious disease physician and professor of medicine and microbiology, and the chief of the division of Infectious Diseases and travel medicine at MedStar Georgetown University Hospital. She's also the senior Associate Dean for students at the Georgetown University School of Medicine in Washington, DC. Dr. John Faragon is a pharmacist at Albany Medical Center in New York and the regional pharmacy director for the Northeast Caribbean AIDS Education and Training Center. Mr. Damon L. Jacobs is a licensed marriage and family therapist and HIV prevention specialist in New York. Dr. Jonathan Appelbaum is a physician and professor of internal medicine at the Florida State College of Medicine in Tallahassee, Florida.
To provide a little context for our discussion today on this topic, the first oral option for HIV PrEP was approved in 2012 and today there are two oral options and one long-acting injectable for HIV prevention. According to the figures from the Centers for Disease Control and Prevention, only about 30% of the estimated 1.2 million people who could benefit from PrEP were prescribed it in 2021. This is a significant improvement compared to 2017 when only 13% of individuals were prescribed PrEP. However, much work has yet to be done.
Additionally, access and use of PrEP are not equal in all populations that could benefit, in particular in communities of color and in women who are not being prescribed PrEP at the same rates as other communities.
With that, Rasheeta, I know one of your areas of research is on HIV prevention and PrEP in black women. Can you speak to some of the challenges and barriers of PrEP in this population?
Rasheeta Chandler, PhD, RN, FNP-BC:
Absolutely. Thank you so much, Jeff. I am not excluded from this population. Obviously, I'm a Black woman, so on behalf of myself and the Black women who I have the privilege of speaking to about this topic, let me just give you a few things that they have said to me.
Firstly, let me know that PrEP is an option and provide all of the options that I have, and then secondly, don't talk at me. Have a conversation with me. We're a team here to discuss my options to have optimal sexual health outcomes. Include me in the conversation about PrEP. How can that be incorporated into my life, in my routine? Make it convenient for me. Have exclusive ads that highlight me as a PrEP user. Give me a reason to care and make it relevant to me.
I want to highlight a few examples of that and we can go to that phase of it if you want me to, but those are some barriers. I think more specifically there are structural barriers, so direct costs associated with sustaining PrEP adherence, limited availability of PrEP in communities with greatest need, like you mentioned, residential segregation, contextual barriers such as disparities in PrEP prescribing and marketing, and then some personal barriers. I touched on that, just not being aware, not being presented with the option, and then misinformation about PrEP, that this is the age of social media and getting information from so many different sources. Sometimes women just don't know what source to trust. As providers, I find that they do trust us and we need to be the ones initiating these conversations if we have the opportunity to do so.
Dr Kwong:
Great. Thank you so much. Damon, I know you've been an internationally recognized PrEP advocate. What have you seen as some of the biggest barriers to PrEP uptake, and how do you think we can address some of these barriers?
Damon L Jacobs:
I believe, at least in the US, the biggest barrier, or one of them, is the puritanism and the morality that gets in the way of being able to present our communities with accurate scientific data that can improve the quality and quantity of their lives. The "should" and shame around the idea of having several sexual partners, perhaps at the same time, minimizing the beauty and the relevance of sexuality on the continuum of life experience, that seems to freak out a lot of healthcare providers. That gets in the way of saying, "Hey, this is what PrEP can help you with. It can help you be proactive, responsible, and empowered about your pleasure, PrEP. That it can really help you take control of your life, of your body, of your sexuality in a way that's going to improve the quality of your life and the quality of many of your relationships."
As a mental health provider, I can tell you that what PrEP has often been able to do is allow people who are living with HIV and people not living with HIV to connect and date and celebrate their lives and their sexualities in ways that they were not comfortable doing or able to do prior to PrEP. We want to get over the barriers that people might even be having hearing me talk about sex in an explicit way, and if necessary, bring in the other people in your field who can do that if you are not comfortable doing that. Bring in the advocates, the sexual health advocates, the mental health providers, the harm reductionists who are able to work more directly with your consumers if you're not comfortable doing that.
I would say even if you're not comfortable doing that, there's still a question you can ask all your patients or clients or consumers, "How can I help you feel good?" Or, "How can I help you have the kind of sex you want to have?" At least start from there if you don't know what else to do. Once you do that, you demonstrate that even if you don't have all the answers or all the facts, you have shown me as your patient, that you're at least interested in participating in my life in a meaningful, pleasurable way, and that you're interested in providing me medicine over morality. That you're interested in providing me facts over fears, and evidence over the emotions that get in the way of talking about PrEP.
These are all examples of ways that we can normalize sexuality and the beauty and vitality of sexual experience throughout the lifespan for people who are possibly at risk of HIV as well as people living with HIV who have partners whom they might wish to learn how to protect.
Dr Kwong:
Amazing. I love your perspectives and your words of wisdom. Thank you so much. Switching gears a little bit, we're going to talk a little bit about long-acting injectables. In 2022, cabotegravir became the first long-acting injectable option for PrEP. How do you see this fitting into HIV prevention and in which patients do you, or would you recommend injectable PrEP? I'll turn this to Jon Appelbaum and Princy.
John, would you like to go first?
Jon Appelbaum, MD:
Sure. Like many of us, I welcomed another possible form of giving PrEP in addition to oral, long-acting injectable is something that many of our patients have been asking for, both for the treatment of HIV, but also for prevention. Not having to take a pill every day reduces stigma. There are lots of reasons that we welcome it.
I have to tell you, there's been some issues. I mean, it'd be interesting to see what Princy has to say, but we've had access issues for the long-acting coverage by insurance companies. Now that one of the oral formulations is available as a generic, we have insurance companies that are basically telling us which form of PrEP we have to prescribe. Now that we have this as a third option, I think I often will leave it up to, or I will leave it up to patients as part of our shared decision-making and figure out what works best for them. No medication is going to work if they don't take it and so if they don't want to take a pill every day, coming in for an injection every two months is an alternative, but they still need to come in for the injection. There are barriers, but I welcome it. I think there are some structural issues that I mentioned before that we really need to get around to really embrace the fact that we have these options.
Dr Kwong:
Great. Princy, do you have any thoughts?
Princy Kumar, MD:
Yeah, if I could just add to what just... Jon said it well, but if I could add a couple of things. All three forms of PrEP work great. All three forms are... All three available formulations work very well. The reason it has fallen short of expectations is really because of suboptimal uptake and adherence. Adherence is really the major drawback that has really prevented PrEP from being 100% effective. That may be partially overcome by injectable cabotegravir.
If you take a minute and look at the data, we can just take a minute and look at 083 that looked at cabotegravir, long-acting cabotegravir versus FTC-TDF. There was a 66% reduction in participants who got the injectable cabotegravir. Many people said, "Well, that's all from adherence," but it's probably not all from adherence because if you go look at the data, 72% of people were actually taking the FTC-TDF when they measured. It's partly it helps with adherence, the injectable cabotegravir, but it may not be all adherence. I think for all of those reasons, having an option of an injectable preparation, especially for people who are not able to be adherent to a regimen every single day, I think is very powerful.
Dr Kwong:
Great. Thank you both for your perspectives. I'm going to switch gears again a little bit here. John Faragon, one of the challenges some clinicians and consumers have expressed relates to some of the potential side effects of either oral or injectable PrEP. What information do you share with colleagues or clients who may be worried about these issues?
John Faragon, PharmD, BCPS, BCGP, AAHIVP:
I think all three of these options are very well tolerated. I think for people who want oral PrEP, it's usually going to be some GI intolerance initially You can potentially put people on Zofran too in the first couple of days if you need to for some nausea. That might potentially help.
The injectables, obviously the biggest issue for most patients are going to be the injection site reactions, which are pretty common. Again, there are ways. You can use hot and hot or cold packs can sometimes help, over-the-counter analgesics sometimes will help with that as well for some patients.
I think the most important thing is that regardless of which option is right for you as a patient, they all work very well they're all very effective and they obviously are well tolerated. I'm sure there's going to be differences with each patient that you kind of have to be aware of. But those are some of the things that we share typically with our patients who are starting PrEP.
Just one other thing with the injectables and Dr. Appelbaum, John alluded to this there are some challenges with some of the billing too, and sometimes can be difficult. I think having some kind of a protocol in place where it becomes easier to do the billing in a specific way each time so that institutions are getting paid properly for the medications as well, I think is a big help in trying to roll out injectable PrEP for our populations.
Dr Kwong:
Great. Well, I know we've touched on so many different topics and we could speak for hours on many of these issues, but I think we've really touched on issues of stigma, of organizational or systemic issues that provide or create barriers to access for PrEP, we've talked about some of the options and availability to help patients find the right option for them, and John, you've talked about strategies and some of the ways that we need to still further enhance our PrEP delivery system to help increase access for everyone.
Thank you all for your input and perspectives. I know we covered a lot, but for those of you who would like additional information about HIV PrEP or to learn ways to implement PrEP in your organization, there are a variety of resources available, including the CDC's HIV Nexus Clinician Resource website, as well as the Clinical Consultation Center PrEP Line, and the regional and local AIDS education and training centers located across the US.
Thank you for viewing this video. Working together we can end the HIV epidemic.