James Conniff, MD, and Ann Evensen, MD

James Conniff, MD, and Ann Evensen, MD

An article by the UW Department of Family Medicine and Community Health’s (DFMCH) James Conniff, MD, and Ann Evensen, MD, aims to increase primary care physicians’ awareness and understanding of a new office-based strategy for preventing HIV in high-risk patients.

In the Journal of the American Board of Family Medicine, Drs. Conniff and Evensen review how preexposure prophylaxis (PrEP)—the daily use of antiretroviral medication to reduce the risk of acquiring HIV—can complement other established strategies for HIV prevention.

Reaching High-Risk Individuals

In May 2014, the Centers for Disease Control and Prevention (CDC), recommended that PrEP (with daily oral dosing of tenofovir/emtricitabine) be made available for people who do not have HIV, but who are at high risk for acquiring it. This includes nonmonogamous men who have sex with men (MSM), certain injection drug users (IDU) and heterosexual women who have sex with MSM or IDUs.

Key points:

  • In May 2014, the CDC began recommending PrEP for HIV prevention in high-risk individuals.
  • Use of PrEP in a primary care setting may reach more at-risk individuals than use in an HIV or infectious disease clinic.
  • Appropriate clinical management includes behavioral screening, laboratory testing, and careful follow-up.

According to the CDC, when used consistently, PrEP reduces the risk of getting HIV from sex by more than 90 percent. Among people who inject drugs, it reduces the risk of getting HIV by more than 70 percent.

Despite the CDC’s recommendation, Drs. Conniff and Evensen cited studies that showed only 40 percent of infectious disease specialists and primary care providers thought PrEP should be made available to all high-risk individuals, and that only 9 percent of infectious disease specialists had prescribed it.

“Patients who might benefit from PrEP are likely not presenting to infectious disease specialists,” they wrote. “If more family physicians and other primary care providers feel comfortable prescribing PrEP, this strategy for reducing HIV prevalence may reach more individuals who are vulnerable to infection.”

Clinical Guidelines and Ethical Considerations

Drs. Conniff and Evensen outlined how clinicians must first provide initial behavioral screening to identify patients who might be appropriate candidates for PrEP—and then obtain baseline laboratory values before prescribing the medication.

Patients taking PrEP must also return for regular follow-up office visits to ensure adherence, provide ongoing counseling, test for HIV, and assess side effects.

The authors also explained that although using PrEP to prevent HIV may benefit the individual as well as the wider community, there are ethical implications to consider. These include the cost-effectiveness of the intervention, and the concern that increased PrEP prescribing could divert treatment away from HIV-infected patients, especially in resource-limited settings, thereby exacerbating health inequities.

“Primary care providers are at the front line of PrEP implementation and should embrace this opportunity to increase awareness of PrEP and to prevent HIV infection among those at risk,” the authors concluded.

Dr. Conniff is a graduate of the DFMCH’s Madison residency program and primary care research fellowship program. Dr. Evensen is an associate professor at the DFMCH.

Published: June 2016