PrEP at 10: Prescriptions Have Increased but Underutilization Remains a Challenge

This year marks the 10 year anniversary since the FDA approved emtricitabine-tenofovir (Truvada) for Pre-Exposure Prophylaxis (PrEP) thus sparking the beginning of a daily pill designed to prevent new HIV infections. This was seen as a breakthrough for trying to stem the tide of new infections.

PrEP continues to be a highly efficacious treatment strategy in HIV prevention. According to the Centers for Disease Control and Prevention (CDC), PrEP reduces the risk of getting HIV from sex by about 99% when taken as prescribed.

“All of us who have been doing this for so long were able to exhale a little bit as a way to get ahead of this pandemic, because we have not gotten far enough with the vaccine,” Emily Rymland, DNP FNP-C, AAHIVS-certified HIV specialist and director of Clinical Services at Nurx, said of the introduction of PrEP. “This is our alternative to a vaccine, which has been super exciting and wonderful.”

Along with the intended HIV prophylaxis element, PrEP may offer other peripheral benefits. The results from a recent study showed that rates of bacterial sexually transmissible infections stabilized among gay and bisexual men in Australia who received PrEP. The incidence of chlamydia fell from 48.7 cases per 100 person-years in July-December, 2016, to 42 cases per 100 person-years in July-December, 2019. Incidence of gonorrhea fell from 45.5 to 37.2 cases per 100 person-years.

In the ensuing years since PrEP’s approval, it has seen an increase in the number of prescriptions but it still remains underutilized. In the United States, there is a regional component to whether people are taking it. Rymland says there is a large issue in the south. “In southern states especially in Georgia…in Atlanta [HIV transmission rates] are huge, but no one has every spoken to them [patients] about it,” Rymland said.

The southern US continues to lead the country in transmission rates and is the lowest in PrEP utilization. According to AIDSVu, the south accounted for more than half of all new HIV diagnoses in the US in the 2016 yet only 30% of all PrEP users in the country. AIDSVu also reported the statistics of PrEP usage throughout the US. The northeast has 47.4 PrEP users per 100,000 population; the west has 28.1 PrEP users per 100,000 population; the midwest has 23.5 PrEP users per 100,000 population; and the south has 22.6 PrEP users per 100,000 population.

As outliers, both Texas and Florida are included in the top five states using PrEP. Collectively, those five states accounted for nearly 50% of all PrEP users in the country.

As an HIV specialist, Rymland is on the frontlines often telling young people under the age of 25 that they are HIV-positive. Rymland sees a big part of the underutilization problem as a lack of communication between primary care providers and patients. “They don’t feel that sexual health is part of their primary care…We [need to] change that dynamic with health care providers really jumping in and saying, ‘you don’t have to tell me what types of sex you are having, if you feel you need PrEP, I’m going to give it to you.’”

Another issue she sees is general awareness about PrEP. She says men who have sex with men (MSM) have a tendency to know about PrEP, but many others do not. Rymland sees the underutilization challenges in layers with multiple components to it. These issues include the aforementioned lack of education and awareness about PrEP, as well as accessibility to it, and insurance and financial shortcomings.

Contagion spoke to Rymland about PrEP’s anniversary and the utilization challenges that remain.