Providers' concerns about behavior change don't justify withholding HIV PrEP
Preexposure prophylaxis (PrEP) for HIV is an antiretroviral pill that is over 90% effective in preventing HIV acquisition when taken as prescribed. A new Perspective, published in the February 7 issue of the New England Journal of Medicine, examines clinicians' concerns and biases toward prescribing PrEP and suggests strategies to mitigate those biases. The Perspective, "Risk Compensation and Clinical Decision Making—The Case of HIV Preexposure Prophylaxis," is coauthored by scientists at the Harvard Pilgrim Health Care Institute and Harvard Medical School, George Washington University, and Kaiser Permanente.
The U.S. Centers for Disease Control and Prevention estimates that 1.1 million people in the United States are at risk of acquiring HIV infection, yet only about 100,000 used PrEP in 2017. Clinicians' concerns about potential changes in sexual behavior among users may be one reason for the slow uptake of PrEP. Although PrEP protects people from acquiring HIV, users might have more partners or more condomless sex, thereby increasing their risk of non-HIV sexually transmitted infections. This anticipated pattern of behavior—greater risk taking in response to an increased sense of protection—is in keeping with a theory called risk compensation. Although many PrEP users don't change their condom use, providers' anticipation of behavior change can make them reluctant to prescribe PrEP.
"PrEP does not protect against non-HIV sexually transmitted infections, but concerns about risk compensation do not justify withholding PrEP," said lead author Julia Marcus, Assistant Professor of Population Medicine at the Harvard Pilgrim Health Care Institute and Harvard Medical School. "According to the World Health Organization, sexual health is not only the absence of disease, but a holistic state of physical, emotional, mental, and social well-being in relation to sexuality. By enabling condomless sex with less fear of HIV transmission, PrEP has the potential to facilitate the intimacy and pleasure that can enhance sexual well-being for many people."
As the authors note, however, previous studies have suggested that clinicians may discount the importance of the psychological aspects of sexual health.
The authors propose three initiatives that could promote more patient-centered and equitable dissemination of PrEP. First, clinical guidelines and training curricula could explicitly endorse offering PrEP to patients regardless of intended condom use. Second, clinicians could engage patients in ways that help them make informed decisions about options for HIV prevention—including PrEP and condoms—that are in keeping with their values and desires. Finally, clinical training curricula could include strategies for minimizing the influence of personal attitudes regarding sexuality on clinical decision making.
"Patient-centered care requires recognizing that disease prevention may not be the only health outcome important to patients," said coauthor Sarah Calabrese, Assistant Professor of Psychology at George Washington University. "Ultimately, making PrEP available to patients regardless of their intended condom use will promote patients' sexual health and public health efforts to combat the ongoing HIV epidemic."