Stigma linked to pre-exposure prophylaxis (PrEP) continues to be one of the most challenging hurdles in HIV care, both for providers and patients, but both medical advancements and evolution of care practices might change that.
A 2022 study published in AIDS Research and Therapy examined attitudes towards PrEP among men who have sex with men (MSM) in Canada. After adjustments, they found high PrEP-related stigma more than twice as likely among former PrEP users than among current PrEP users.
A 2020 review in Current AIDS/HIV Reports noted that “PrEP users are commonly stereotyped as sexually irresponsible, promiscuous, and immoral” and linked these factors to lack of adherence or even discontinuation of PrEP among those at high risk for acquiring HIV infection. A 2020 report in Sexually Transmitted Infections also found higher PrEP-related stigma linked to transgender or gender non-conforming, injection drug use, unstable housing, and mental health issues.
However, recent medical advancements promise to give these patients greater support and discretion. In December 2021, FDA approved long-acting injectable cabotegravir (Apretude) for HIV prevention. This regimen consists of two injections administered a month apart, followed by injections every 2 months afterwards. Research suggests that patients across different demographics tend to prefer a long-acting injectable prevention option over a daily pill.
Monica Gandhi, MD, of the University of California San Francisco, characterized the long-acting injectable PrEP option as “one of the most important ways that the HIV community has tried to combat stigma linked to PrEP use.”
“Taking a pill every day can be stigmatizing for patients who may not want roommates or family members to know they are at risk of HIV,” she said. “An injectable delivered every 8 weeks can be very destigmatizing in terms of preventing HIV and is a major advance.”
Indeed, the World Health Organization (WHO) has endorsed long-acting injectable cabotegravir as another option for HIV prevention for those who are at high risk of acquiring HIV.
‘Meeting Patients Where They’re At’
Antonio Urbina, MD, of the Icahn School of Medicine at Mount Sinai in New York City, commented that while patients have “a lot of internal stigma about disclosing their sexual risk,” the medical community can help play a role in helping to alleviate that stigma. Nevertheless, there are still some barriers to PrEP use that Urbina characterized as “provider-facing.”
“Some providers still feel uncomfortable with taking a sexual history [or] addressing the sexual needs of patients. It would be helpful if more providers were more comfortable addressing sexual health,” he added.
Urbina pointed to “status-neutral” care — offering every patient who comes into a clinic an HIV test, rather than just certain groups — as one of the ways where providers are helping to ease that stigma.
CDC defines status-neutral care as a “whole person approach” that aims to address “social and structural barriers to engagement in biomedical prevention,” such as PrEP, as well as HIV treatment and care. They added that “status neutral approaches promote health equity by putting client needs above HIV status to improve care and eliminate stigma.”
Urbina also said that folding HIV prevention more into primary care might help to alleviate stigma, because it would “meet patients where they’re at.” Urbina noted that there is a large disparity in PrEP use among Black women and suggested that it might help those patients if they could consult with their ob/gyn provider about HIV prevention.
Moreover, Urbina discussed the need for community health centers “that are not designated as HIV [clinics] specifically, just holistic comprehensive primary care” so that going in for HIV care “doesn’t ‘out’ the person,” Urbina added.
In August, the U.S. Preventive Services Task Force (USPSTF) reaffirmed their grade A recommendation to offer PrEP to those at increased risk of HIV “after the clinician and patient have discussed PrEP and the patient agrees,” they wrote.
But talking to a doctor in and of itself might be a barrier to PrEP uptake, especially as Urbina noted that there is still considerable “mistrust or distrust in the healthcare sector,” especially among marginalized and vulnerable populations.
In regard to “meeting people where they’re at,” Urbina emphasized the importance of community outreach.
“What we found successful is vans that go out and offer HIV or STI [sexually transmitted infection] testing, going to venues [such as sex clubs] where populations are at increased risk of HIV,” he said. “Providing them with education, information, and point-of-care testing to start that conversation is going to be the most important. Otherwise, we’re just expecting people to come in.”