How Can Primary Care Providers Help Their Patients Decide if PrEP Is Right for Them?

Kenneth Mayer, MD, Medical Research Director, Professor of Medicine, Fenway Health, Harvard University, explains why primary care providers need to have a good sense of their patients in order to help them decide if PrEP is right for them.

Interview Transcript (slightly modified for readability)

“Many people have expressed concerns [that] the use of [pre-exposure prophylaxis] PrEP will mean that people won’t use condoms, and clinicians have to take a couple issues into account. PrEP, if taken every day, is highly effective against HIV, so if we don’t want people to become infected, we certainly want them to be using PrEP. But the key is working with the patient. If the person’s already using condoms and doesn’t have a problem using condoms, then we don’t want to say, ‘Gee, start taking a pill instead.’ So, you have to kind of know your patient.

Some people don’t need PrEP because they’re not at risk. Other people have no problem using condoms. On the other hand, we know that a lot of people don’t like condoms, or don’t use them regularly, and those are the individuals who are at very high risk for HIV. The good thing about PrEP is that if you’re risky for about a year in your life, or when you’re young, [maybe] for 5 years, the day you are not risky anymore, you can stop PrEP and you don’t have to take the medicine for the rest of your life. Once you become HIV-infected, if you’re 18-years-old, right now we don’t have a cure, so you have to be on the medication for the rest of your life; so, that’s the balance.

But the reason why we don’t want to make it [the choice of] ‘PrEP or condoms’ is that some people are very risky in terms of HIV—[those] who have multiple sexual partners, for example, [or] somebody who’s a sex worker. That individual is not just at risk for HIV; they’re at risk for bacterial [sexually-transmitted infection] STIs. So, for example, they could get gonorrhea; they could get syphilis [or] chlamydia. The medication for PrEP will not protect them against that, [and] so, if those individuals are concerned about the other STIs, they still need to use condoms.

It’s a nuanced discussion. Some people say, ‘Well, I’m not so worried about those infections; I can get screened. I just can’t use condoms; I’m not able to maintain an erection. My quality of life is not good.’ For that person, PrEP is preferable. On the other hand, if somebody says, ‘I would be so freaked out if I had any of these infections. What could I do to protect myself?’ Then I’d say, ‘Well, PrEP will give you protection against HIV. Condoms do sometimes break, so they [don’t offer] 100% [protection].’ [In that case], if [they] want a ‘belt and suspenders’ approach, [I would say], ‘condoms plus PrEP,’ and there are some people who will elect for that.

But I think it, again, gets back to primary care providers really having a good sense of their patients, and talking to them, and trying to understand what their patterns of sexual behavior [are], and what the tradeoffs they’re willing to make [are].

The good thing about PrEP is now, it’s another tool that we have at our disposal. But certainly, it’s not good for providers to just write a prescription and not talk to [their] patients about it, because it’s really important that the patients are motivated to be adherent, and they understand what protection it provides, [and] what protection it doesn’t. Even though the incidence of side effects is low, it’s not zero, so, it’s very important for the patient to be an informed consumer before starting PrEP.”