Adolescent HIV Prevention: Overcoming the PrEP "Purview Paradox"

The “purview paradox” refers to a contradiction in which primary care physicians consider pre-exposure prophylaxis (PrEP) to be beyond their purview, but experienced HIV care specialists tend to work in contexts where patients are already living with HIV.

The purview paradox is particularly present in adolescent HIV prevention. Primary care physicians may doubt the ability of their patients to adhere to a daily medication, have legal concerns about whether sexual health services can be kept confidential from parents, or may have reservations when discussing a younger patient’s sexual activity.

The authors of a recent analysis in JAMA Pediatrics detailed adolescent PrEP uptake in the US and advised health care professionals to be proactive in discussing PrEP with younger patients.

Uptake of PrEP has been slow, particularly among at-risk individuals between 13-19 years of age. Primary care clinicians and specialists do not routinely offer adolescents HIV testing, despite US Centers for Disease Control and Prevention (CDC) recommendations in favor of doing so.

Results were gathered from 58 articles found by the review team via PubMed and Embase searches for studies published between 2009-2019, with the addition of a few publications considered highly relevant or often referenced within the HIV prevention clinical discourse.

The findings indicated 37,377 new HIV diagnoses documented in the US in 2018. Of these, 7734 occurred in people between 12-24 years of age. Within these 7734 new diagnoses among adolescents and young adults, 1707 were recorded among adolescents aged 13-19 years.

About two-thirds of the diagnoses were accounted for by young black men who have sex with men.

“Preexposure prophylaxis awareness and engagement are lowest in adolescents with the greatest risk for HIV,” the investigators observed.

Primary care providers who are in the best position to offer services like PrEP to a broader share of the population may be discouraged by uncertainty about the rights of adolescents to access PrEP outside parental influence, or may only raise sexual health when led by perceptions about a patient’s HIV risk.

Broadening the availability of PrEP for adolescents who would benefit from it could substantially impact national HIV prevention efforts. Primary care providers can be proactive in their involvement in this public health project, taking steps for routinizing sexual history and risk assessment evaluations. And there are also opportunities for social interventions taking place outside the clinical setting.

“Technological interventions are becoming increasingly popular, serving as delivery tools for sexual health information and for promoting HIV testing and medication adherence," investigators wrote. "Widespread media and internet coverage led to a 50% increase in PrEP awareness over a 3-year period. The success of social media, gaming apps, and ubiquitous internet access have since been used in PrEP campaigns and have proven beneficial."

Many of the clinicians who are discouraged by the PrEP purview paradox are actually the providers on the frontline of HIV prevention. Asking about sexual activity in a nonjudgmental manner, testing for HIV as well as other STIs, and discussing PrEP are beneficial additions to clinical practice.

“The fear of invading a patient’s sexual privacy, which prevents most clinicians from obtaining sexual history, must be overcome as part of efforts toward sensitizing adolescents to adopt PrEP as a component of multiple HIV prevention strategies,” the review authors wrote, adding that “identification and transformation of individual, community, systemic, and organizational barriers remain necessary to increase the use of PrEP in this unique group.”