Our failure to promote PrEP to at risk patients

The medical profession has failed in the area of preventative healthcare yet again. We have failed in an area which makes us “uncomfortable” when we discuss it with patients. That area is sexual health, and disease prevention. We fail because we are “uncomfortable”. We are failing to prevent a disease with the power to kill, when we have had some tools to prevent it for years. I am talking about HIV. Perhaps most shamefully of all, we are failing to use a powerful new tool in our therapeutic arsenal to prevent HIV transmission.

It is most certainly true that we understand a great deal about the HIV virus’ biology, and we have used that knowledge to create treatments that prolong the lives of HIV positive individuals. Perhaps most importantly, these drugs provide good quality of life. Now, we have found that these same drugs used for treatment of HIV infection can be used to prevent infection in the first place (a strategy called Pre-exposure prophylaxis, or PrEP). To me, this is almost a no brainer. There is one hang up however: the possibility of promoting resistance to antiviral drugs.

Consider the fact that patients are notoriously bad at taking medications as prescribed. All medicines. Not just antivirals. Physicians have already raised a new generation of super-bacteria by overusing antibiotics. A problem which is only compounded by the fact that many patients never finish the prescribed course. Individuals, regardless of HIV status, are bad at taking medicine as directed. So when HIV positive individuals don’t take their medications quite like they should, that is already a situation that can promote resistance. I contend that providing patients with PrEP is not going to make the problem of emerging resistance any worse than it already is. There is obviously room for debate on this issue, and I am certainly not an expert by any stretch of the imagination.

Failing to offer PrEP to appropriate patients is just as bad as failing to offer vaccination to a child. It is an opportunity to prevent disease that is being overlooked because it is “uncomfortable” to ask patients about sex. It should not be surprising that physicians are failing to offer PrEP, because we also have an abysmal track record of offering HIV testing. The CDC recommends that patients between the ages of 13 years, and 64 years be screened for HIV. The American College of Physicians recommends that physicians make HIV testing a part of routine health screenings. When was the last time your doctor suggested that you be tested?

Last time I checked, we do all kinds of things in medicine that make patients uncomfortable. We need to ask our patients about sex. Are they having sex? With what types of people do they prefer to have sex? Do they have one partner, or several? Just because a patient is elderly doesn’t mean that they aren’t having sex. Just because someone is in a relationship with a male at the present time doesn’t mean that they aren’t now, or have never had sex with a female. Just because a patient is married, doesn’t mean that they are monogamous. In order to know who to offer PrEP to, we need more information about our patients’ sexual practices.

To get this information, patients need to feel safe talking to us. There have been times when I have been a patient myself, and a physician would say something along the lines of “So, do you have a girlfriend?” This does not make me angry. Both as a medical student, and as a gay man this just makes me mentally sigh. I sit there and contemplate if it’s worth it or not to correct the situation. To educate the physician that no, I do not have a girlfriend, but I do have a boyfriend. Should I suggest that the physician should try more open ended questioning, signaling that he/she is ready to hear my story if I am ready to tell it.

The medical profession has a long track record of failing to promote preventative healthcare. It also has a track record of avoiding issues that are “uncomfortable”. It really should be no surprise that we have failed so profoundly to offer HIV screening and PrEP to our patients.



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