PrEP Is Approved for Adolescents: Why Isn't it Being Prescribed More?

The US Food and Drug Administration (FDA) approved pre-exposure prophylaxis (PrEP) for use in adolescents in May 2018, but hurdles at the patient, physician, and health care system levels can sometimes hinder accessibility.

According to statistics from the US Centers for Disease Control and Prevention, adolescents aged 13 to 24 comprised 21% of all new HIV diagnoses in the United States in 2016.

“Adolescents and young adults continue to have an increased HIV incidence rate nationally,” Caroline Carnevale, FNP, MPH, AAHIVS, DNP, student at Yale University, told Contagion®.

When taken consistently, PrEP—such as once-daily oral Truvada (emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg)—can reduce the risk of HIV infection by 92%.

But the problem with PrEP is not that health care providers don’t know it exists; on the contrary—a recent study led by Carnevale and published in the Journal of Pediatric Health Care includes data from a survey of 162 adolescent providers. Of those providers questioned, 93.2% had heard of PrEP but only 35.2% had ever prescribed it to a patient.

Which begs the question—why?

“The research has shown that providers feel that they lack the formal training needed to prescribe PrEP and we believe this is part of the reason for providers feeling uncomfortable prescribing PrEP to adolescents,” Carnevale, who is also the principal investigator of the HIV Prevention Program, part of New York Presbyterian Hospital’s Comprehensive Health Program, said. “Also, while providers may be aware that they are prescribing a medication that can be given to adolescents without parental consent (in New York and other states), [they] may be concerned about prescribing TDF/FTC (tenofovir/emtricitabine) without involving the parents.”

A separate study, published in the Journal of Adolescent Health (JAH), had similar findings.

“The behaviors that place a young person at risk of HIV are often not known by the youth’s parent,” Tanya L. Kowalczyk Mullins, MD, MS, FSAHM, FAAP, director of research in the Division of Adolescent and Transition Medicine at Cincinnati Children’s Hospital Medical Center, and author of the JAH study, explained to Contagion®.

“Our work shows that physicians are very concerned about protecting the adolescent’s confidentiality with respect to PrEP use. Further, the legal ability of health care providers to prescribe PrEP without parental involvement is unclear in many jurisdictions,” Dr. Mullins continued. “In addition, concerns about how youth would pay for PrEP were prevalent among our physician participants. Although some financial assistance programs exist, it is unclear whether minor-aged youth could realistically access these programs without parental involvement.”

Another issue that comes with prescribing PrEP to adolescents is adherence.

“Providers must be able to take the extra time to discuss the importance of PrEP adherence with their patients and monitor the adherence monthly if need be,” Carnevale said. “Also, providers must be comfortable with discussing sexual behavior (whether its retrospective or prospective behavior) with their patients. Asking patients what their ideal sexual life would be or what do they want for their sexual life can be important questions that can get to the route of how PrEP can be helpful (in addition to condoms) in preventing HIV.”

To that end, Carnevale and her team of investigators developed a “comprehensive provider curriculum” to help guide health care professionals through adolescent-specific issues related to PrEP screening, prescribing, and monitoring. The proposed program was reviewed by a 7-expert panel of nursing, medical, and public health professionals.

“With our curriculum, we hope to give providers the tools needed to administer PrEP to adolescents who may be at risk of HIV acquisition,” she told Contagion®. “From information about the clinical trials associated with PrEP efficacy to what visit schedule to use when administering PrEP to adolescents, we hope to make this information more accessible to adolescent providers with the goal of reducing the incidence of HIV in this population.”