Think your patients are not at risk for HIV? Think Again
Incorporate PrEP into your medical practice
by Theo W. Hodge, Jr., MD
African Americans face a disproportionate risk of acquiring HIV and account for over half of HIV/AIDS related deaths. So, I was surprised when my colleague answered, “My patient population is simply not at risk,” after I questioned him about HIV testing in his practice.
“Hmmm,” I responded. “Based on current infections rates, the CDC determined that Washingtonians have a 1 out of 13 lifetime risk of acquisition of HIV. It is the highest in the country. You practice in DC and so your population is at risk.”
“I treat mainly adult men and women of the African American community and from what I gather this is a white gay male disease,” he countered.
Recognizing a teachable moment, I grabbed a cup of coffee and sat down with my colleague.
Consider the Current HIV Statistics
In March 2016, the CDC reported lifetime risks for acquisition of HIV. The results were quite disturbing. While the overall lifetime risk of HIV in the United States is 1 in 99, African American women have a 1 in 48 lifetime risk, African American men overall have a 1 in 20 risk, and African American men who have sex with men have a 1 in 2 lifetime risk of becoming HIV positive. Of deaths attributed to HIV/AIDS in 2014, 53% were African American.
Assemble Your HIV Prevention Toolbox
In 2018 the life expectancy of someone living with HIV approaches that of the uninfected, provided they are receiving appropriate therapy. However, HIV remains an incurable medical condition of which prevention of its acquisition remains a mandate.
The HIV prevention toolbox should be a staple of any medical practice but particularly in the primary care practice. These powerful prevention tools include:
- Testing for HIV,
- Prescribing antivirals with adherence to those who are positive,
- Educating those who are negative on how to remain negative, and
- Prescribing PrEP to those who are negative and at high risk for infection.
Pre-Exposure Prophylaxis (PrEP) is the use of a drug to prevent a disease in people who have not yet been exposed to the disease-causing agent. In 2012, the Food and Drug Administration (FDA) approved a drug, Truvada, to prevent HIV. The drug is used in combination with safer sex practices to reduce the risk of sexually acquired HIV-1 in adults at high risk and in several studies found to have prevented HIV over 90% of the time in the adherent patient. At present Truvada is the only drug approved for this purpose.
Consider PrEP for your eligible patients.
Obtaining sexual histories to ascertain risk for HIV should be an integral part of a medical history in the primary care office. Those who are eligible for PrEP are the uninfected who engage in sex with HIV positive partners or who engage in sex in a high prevalence area or sexual network, and have one or more of the following:
- Partners of unknown HIV status
- Inconsistent or no condom use
- Use of illicit drugs or alcohol dependence
- Diagnosis of sexually transmitted diseases
- Exchange of sex for commodities
During Infectious Diseases (ID) Week in October 2017, several abstracts indicated limited awareness of PrEP among healthcare professionals including primary care physicians. Vigorous efforts in the physician’s office are needed to bring this powerful tool to all eligible adults but particularly to populations most heavily burdened by HIV.
The Centers for Disease Control and Prevention (CDC) will soon release materials to assist clinicians with prescribing PrEP and PEP and educating patients about HIV prevention. Pre-order these materials by emailing: prescribeHIVprevention@CDC.gov
Resources are also available to help health care providers learn more about the issues facing Black gay men. The His Health website, www.hishealth.org, is the product of collaboration among Black gay men, healthcare and service providers, public health professionals, federal health agencies, LGBT advocates, and community stakeholders. It offers patient-centered strategies and continuing medical education programs to improve the standard of care for Black gay men.