Current Barriers to HIV PrEP in the United States

In part 1 of this 3-part episode, Jeffrey Kwong, DNP, MPH, ANP-BC, talks about the barriers patients may experience in utilizing HIV pre-exposure prophylaxis (PrEP) and what clinicians need to know when informing their patients about HIV PrEP.

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Listen to part 2 and part 3 of this 3-part episode.

Jeffrey Kwong, DNP, MPH, ANP-BC, is a professor in the division of advanced nursing practice at Rutgers School of Nursing (Newark, New Jersey). 



Jessica Ganga: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your host Jessica Ganga with Consultant360 a multidisciplinary medical information network, along with your moderator, Jessica Bard.

Nearly 37,000 people were diagnosed with HIV and an estimated 1.2 million people lived with HIV in the United States in 2019, according to the most recent data available from the Centers for Disease Control and Prevention.

 Here with us today to speak about HIV Pre-exposure prophylaxis is Dr Jeffrey Kwong, who is a professor in the division of advanced nursing practice at Rutgers School of Nursing. Let’s listen in.

Jessica Bard: We're talking about HIV PrEP today. What are individual and systemic barriers to PrEP usage in the United States?

Jeffrey Kwong, DNP, MPH, ANP-BCSure. That's a great question. Just for the audience just to make sure everybody understands and we're all on the same page, when we talk about PrEP or pre-exposure prophylaxis specifically you're talking about HIV prevention and biomedical options to prevent HIV. This is something that is relatively new. When I say relatively new, only a little bit more than 10 years or so that this tool to prevent HIV has become available to us and has been approved fully by the FDA.

Currently, we have three options available for folks to help reduce or minimize the risk of HIV, but of course, we know that uptake of PrEP has not been as great as we would have liked that to be. I think there are many different barriers or factors that go into that both at the individual level, as you asked about, as well as systemic level.

So at the individual level, I think the primary piece is related to the fact that people just don't know that PrEP is an option that is available to them. Part of that relates to some of the systemic level barriers, but I'll get to that in just a bit. But one is just people aren't aware that this is an option that's available to them. Two, there still are issues around stigma and stigma around both HIV in and of itself, but also in terms of the populations that may acquire HIV. So I think people think that being on PrEP or taking PrEP might suggest that one is in a high-risk sexual group or sexually promiscuous, and there's a lot of stigma around that when in fact, that should not be the case. There's also concerns that if you're on PrEP, that means you might be at risk for injection or that you're using injection drugs or that there are other things that are associated with that that really carry a lot of stigma, which places a big burden on individuals and prevents them from accessing this critical service or this critical tool.

There are other issues as well at the individual level. Even things like people may not know how to pay for it or there might be concerns about cost or insurance access. As part of PrEP, the protocol involves people coming in or at least getting testing for STIs and HIV on a regular basis about every three months or so. For some people, things like transportation and getting to and from a testing center is a challenge in and of itself. Thankfully with telehealth and TelePrEP services that are now available, that has been something that might address some of those barriers. But those are some of the key things that I think of right off the top of my head when I think of individual barriers.

In terms of system level barriers, one of the biggest ones that has been discussed is really that providers are not talking about it with their patients or they're not offering it as an option to people who may very well benefit from this intervention. Part of that is that providers may feel that, "It's an HIV medication, and I'm not an HIV specialist, so I don't know how to deal with that." They have to go see an infectious disease specialist for PrEP, which is not the case. I want to make that very clear that we in fact say that PrEP is primary care. This is a prevention tool and so making sure that we can address and educate primary care providers, women's health providers, urgent care providers, anybody who sees anybody sort of at the front line, is eligible to educate, inform, and recommend PrEP for their patients. So kind of dealing with some of those system level barriers is key.

The other thing also is, as I mentioned, sort of insurance access and making sure that people can get the medication. There are generic options, there are branded options and some insurance companies who people feel make it a barrier in terms of getting the medications because of prior approvals, et cetera. That has been an issue for some of my patients that are here in terms of feedback.

Jessica Bard: So you mentioned awareness, stigma, et cetera. What are strategies to address these issues?

Dr Jeffrey Kwong: Sure. So just like with HIV testing or HIV treatment, and just as an example, I think one way to address some of these issues in terms of stigma is to have people talk about it. Have the public health department in New York City where I practice and live is very proactive in terms of public health campaigns and putting information out to the public to talk about PrEP that depicts people of all walks of life using and talking about PrEP. I think that's one of the best ways to do it.

The other thing is really educating and focusing on providers and getting people trained in their medical education, whatever health profession track they're in, talking about PrEP and understanding that this isn't about anybody's particular "lifestyle" or anything other than that. This is again, it's a prevention tool. We don't stigmatize eating healthier, we don't stigmatize exercise, we shouldn't stigmatize HIV prevention either. I think talking about it, educating people, normalizing it as much as possible is one way to make this less stigmatizing.

Jessica Bard: Right. That's well said. What would you say are the overall take-home messages for clinicians? You mentioned infectious disease, primary care, women's health, et cetera. What do they need to know from our conversation today?

Dr Kwong: Sure. So I think the key thing that clinicians, regardless of your practice setting, is to make sure, as part of the current guidelines from the CDC recommend, that all patients be informed about PrEP as an option. So even in patients who you may not necessarily think of that could benefit from this intervention at this time, it's important to just educate and offer them the information about this great intervention.

What I typically do in my clinic visits is even when we get to talking about sexual health and people say, "Oh, well I don't really need to know about PrEP," or, "That doesn't pertain to me," the way that I usually preface that is, "This may not necessarily apply to you at this point in time, but I just wanted to make you aware that there are interventions that people can use or take to help prevent HIV. I can tell you more about it if you wish. Let me know." It may not benefit, again, the person that's sitting in front of you, but they may have a friend, a son, a daughter, a relative who could benefit from this information. Again, that's just one way that we can help normalize the conversation is to just bring it up on a regular basis and make people aware that this is available.

Jessica Bard: Is there anything else that you'd like to add today?

Dr Kwong: Everybody can make a difference by just helping spread the word and let people know that this is something that's available because, as you may or may not know, there is this national anti-epidemic HIV strategy or campaign that really requires all of us to work together. By talking about this with your patients, you can contribute to that initiative.

Jessica Bard: Thank you.