PrEP: Concerns and Controversies
PrEP is a pharmacologic intervention that, according to the CDC, can lower the risk of sexually acquired HIV by more than 90% and the risk of acquiring HIV from injection drug use by more than 70%.17,31 PrEP is a fixed-dose regimen of 1 pill per day that contains 2 HIV medications: tenofovir disoproxil fumarate (TDF) 300 mg and emtricitabine (FTC) 200 mg. The drug, approved for prevention of sexually acquired HIV infection in 2012, is intended for use in individuals with confirmed HIV-negative status and is contraindicated in those who are HIV-positive or those whose HIV status is unknown.23
Disparities in PrEP uptake and in receiving adequate information about PrEP are prominent in black and Latino young MSM communities. In 2015, approximately 500,000 African Americans and nearly 300,000 Latinos across the country could have potentially benefited from PrEP, based on CDC clinical guidelines.32 However, only 7000 prescriptions were filled at retail pharmacies or mail order services for African Americans and only 7600 for Latinos during a similar time period (September 2015-August 2016). While data on race and ethnicity were not available for one-third of the prescription data, the CDC’s analysis found “substantial unmet need” for HIV prevention.32 In a study conducted in Chicago and Houston between 2014 and 2016 among 394 young MSM (16-29 years of age), 12.2% of participants reported ever taking PrEP, but the figures ranged widely, from 29.5% of white to 11.7% of Hispanic to just 4.7% of young black MSM.33
Misinformation and misconceptions among potential PrEP users, prescribers, and in the community can exacerbate existing barriers to uptake and implementation in populations at highest risk for HIV infection.11,34 One survey of 160 gay and bisexual men who were potential PrEP candidates identified 2 main categories of negative stereotypes against PrEP. The first asserts that PrEP users are actually HIV-positive and are lying about their status. The second assumes that PrEP users are promiscuous and do not want to use condoms.34 Some studies have shown insignificant associations between the use of PrEP and increased sexual risk behavior or acquisition of sexually transmitted infections (STIs).35-38 In one study, participants reported “a sense of relief or reprieve from HIV-related stress … a sense of security and less free-floating fear of HIV” that did not necessarily lead to condomless sex.35 A number of more recent studies, however, have reported an increase in the occurrence of bacterial STIs (such as chlamydia, gonorrhea, and syphilis) in people taking PrEP,39-42 suggesting “a need to reinforce counseling and STI diagnosis and treatment efforts” for patients who pursue this course of therapy.39
IMPACT: An Educational Intervention
To help expand HIV prevention practices to underserved populations at increased risk of HIV infection, Haymarket Medical Education led the development of the HIV Prevention Collaborative, active from 2017 to the present. The aim of the collaborative was to build on the CDC’s HIV prevention efforts and draw upon the collective expertise of national organizations that are dedicated to serving black and Latino communities, and experienced in educating these populations on HIV prevention strategies. Members of the collaborative included the American Medical Association, Health HIV, National Coalition for LGBT Health, Morehouse School of Medicine, National Area Health Education Centers (AHEC) Organization, National Hispanic Medical Association, National Medical Association, Urban Health Plan, and Advancing Knowledge in Healthcare (AKH Inc.).
The collaborative partners designed and implemented a CME/CE-certified, sequenced learning initiative known as IMPACT on Health Disparities in HIV Prevention (the acronym stands for Identification, Mitigating risk, PrEP/PEP, Awareness, Condoms, Testing). The initiative developed multiple educational interventions targeting primary care clinicians across the United States who regularly see patients with a high lifetime risk for HIV infection, particularly young MSM of color.
The overarching goal of the educational curriculum was to improve the ability of primary care clinicians to identify individuals likely to benefit from HIV prevention strategies and provide them with access to interventions in a manner that takes into consideration the stigma, socioeconomic issues, and cultural factors that frequently pose significant barriers to the uptake of services.
The IMPACT curriculum consisted of 7 live and online activities, ranging from a national satellite symposium to regional webinars and local workshops:
- A half-day executive summit meeting titled, The Need for HIV Prevention in Diverse Populations: Eliminating Health Disparities, involving representatives from all partners in the collaborative. An e-monograph was published based on the proceedings of this gathering.
- A 2-hour satellite symposium on State-of-the-Art Strategies for HIV Prevention in the LGBTQ Community, presented at SYNChronicity, the 2017 annual meeting of HealthHIV and the National Coalition for LGBT Health. To extend the reach of the program, a webcast of the live event was posted online at myCME.
- A 2-hour satellite symposium at the annual meeting of the National Hispanic Medical Association, Stand Up to HIV: Prevention Strategies for Your Community, offering case-based learning focused on cultural competence and HIV prevention needs in the Hispanic population. A webcast of the proceedings was posted for online learners, along with a case study.
- Three live, 1-hour, case-based national webinars coordinated by the National Medical Association, the National Coalition for LGBT Health, and the National AHEC Organization.
- Five online clinical cases with HIV patients (African American, LGBTQ, Hispanic, Native American, Alaska Native) that provided learners with exposure to patients’ perspectives on HIV prevention.
- Two live, 1-hour workshops on HIV prevention for primary care clinicians at the Morehouse School of Medicine in Atlanta, Georgia, co-sponsored by Morehouse and the Urban Health Plan.
- A 2-hour satellite symposium, Ending HIV: Family Physicians on the Front Line of Prevention, with case-based learning that addressed specific responsibilities of the family physician, held at the Family Medicine Experience (the annual meeting of the American Academy of Family Physicians), followed by an enduring webcast of the symposium and an enduring online case.
After completing each activity, individuals were required to complete a multiple-choice post-test pertaining to the activity and to submit a program evaluation. These surveys collected data on self-reported improvement in knowledge and competence as well as planned practice changes and projected patient benefit. Learners were also asked to identify anticipated barriers to practice change and any additional education they felt they needed to improve their HIV prevention efforts. Eight weeks after the completion of each activity, participants were emailed a follow-up survey asking them to document the specific changes they had made to their practice after participating in the education and what benefits to their patients they observed as a result.
In total, 21,615 clinicians have participated in at least 1 online CME/CE activity, and 11,787 clinicians have claimed continuing education credit for at least 1 activity. Learners include MDs and DOs, physician assistants, nurse practitioners, nurses, and other healthcare professionals. A total of 790 clinicians attended the in-person activities.
Analysis of outcomes data reveals overall significant improvements in clinician knowledge, competence, and practice. Learners were assessed via a baseline pretest, with the same questions asked after completion of each activity. Learners showed meaningful increases in knowledge and competence of key teaching points, with notable rates of improvement from pre-test to post-test — a 104% aggregate improvement in knowledge and a 130% improvement in responses to the competence questions (Figure 2). Although physicians had marginally higher baseline test scores than other professionals, similar rates of improvement were seen across all professional categories. Learners also demonstrated an 87% improvement in knowledge related to the learning objectives, from 47.1% pre-test to 87.9% post-test, based on data gathered from all live and enduring activities.
Figure 2. Increase in knowledge and competence of key teaching points.