This has historically included men who have sex with other men and people who use intravenous (IV) drugs like opioids. Now, the Centers for Disease Control and Prevention (CDC) is recommending that primary care physicians discuss the use of medications that prevent HIV with all patients who are sexually active, including teenagers.
Ada Stewart, MD, FAAFP, a family physician and board chair and spokesperson for the American Academy of Family Physicians, told Verywell that when taken every day, preexposure prophylaxis (PrEP) is 99% effective at reducing the risk of the sexual transmission of HIV. For people who use IV drugs, Stewart said that the medication is “over 70% effective” at preventing HIV.
Considering that the medications are safe and effective, why aren’t more people taking them?
How Doctors Can Help
One reason why there are many people who are not using PrEP (but could be) is that they have never been offered it by their doctors. They might not even know it’s an option if it’s never come up in a conversation that they’ve had with their healthcare providers.
Stewart commended the CDC on its recommendation because it gives providers a “greater stand as we talk with our patients about PrEP. We have over one million individuals who are living with HIV and many of those don’t know that they have HIV.”
A third option, Apretude (cabotegravir), is an injection that is administered every two months. It recently received FDA approval.
Michelle Collins-Ogle, MD, FAAP, a pediatric infectious disease specialist, assistant professor of pediatrics at Einstein College of Medicine, and a spokesperson for The Infectious Disease Society of America (IDSA), told Verywell that the organization “has supported and has been supporting the use of PrEP in all populations that are sexually active.”
There are also a number of health disparities that affect who takes PrEP—often among the people who are most at risk for HIV. According to the CDC, there are persistent racial, ethnic, and socioeconomic disparities that mean that many people who could benefit from PrEP are not able to access it.
If primary care physicians only think that gay men, transgender people, and IV drug users are the patients who need PrEP, Stewart cautioned that they would be missing many patients who are at risk for HIV and would benefit from prevention.
“As family physicians on the frontlines of all of this, we have recognized that many times we’ve missed the boat for individuals who are candidates for PrEP," said Stewart. “We miss a huge group of individuals who potentially could have benefited from PrEP and therefore miss that opportunity.”
Stewart said that asking all patients about their sexual history and habits should be part of primary care practice, as asking about smoking or alcohol use is. Stewart takes a sexual history on each patient at least once a year and asks them if anything (such as relationship status) has changed.
“There’s so much stigma around HIV that it’s important that we recognize we have to address that issue,” said Stewart. “One way to address it is to talk to all our patients—all our patients, no matter what—about their risk.”
Never Assume HIV Risk
Stewart stressed that physicians should never make assumptions about which patients are most likely to contract HIV. For example, a patient might be monogamous in their relationship, but their partner might not be. A patient could also be in a relationship with a person who uses IV drugs.
“It is not just for men right now. It’s for women—especially African American women,” said Stewart, adding that they care for an 87-year-old female patient who was recently found to be HIV positive.
According to Collins-Ogle, many physicians do not consider women in their 30s for 40s as being at risk for HIV. Therefore, they’re not having these important conversations about sex with them.
“I’ve had many women who have been denied PrEP because the clinician does not perceive that person as being at risk,” said Collins-Ogle. “The primary care clinician is in a great place; [it’s] a great point of entry to receiving prevention services and appropriate sexual health counseling.”
Stewart added that counseling sexually active adolescents about whether PrEP could be right for them is also crucial. Stewart asks the patient’s parents or caregivers to step out of the room, which gives them the opportunity to ask teenagers questions about their sexuality privately.
“You have to establish trust with that young person, and you have to let them know that what you tell me is between you and me and I don’t share my information with anyone else,” added Collins-Ogle, who sees primarily adolescents and young adults in their practice—many of whom are HIV-positive.
If you are not sure if you are at risk for HIV, or you do not know about your options for preventative treatment, you can also bring the topic up with your doctor.
