Removing the word ‘risk’ from discussions of HIV PrEP and focusing more on environment and empowerment concerns are beneficial in this patient population.
When discussing pre-exposure prophylaxis (PrEP) with patients at risk for HIV, sex positive messaging is key, explained Alex R. Mills, PharmD, BCACP, AAHIVP, during his presentation at the APhA 2023 Annual Meeting & Exposition. Specifically, developing the skill of being comfortable talking about sex openly is a critical step in building trust with patients.
“I work with my students a lot on how to do a sexual inventory,” Mills said. “Being comfortable asking those questions in a non-assumptive manner is a great way to identify someone to be on PrEP, and then changing our narrative and our prevention messages related to monitoring and testing may help us increase that uptake for those groups that have currently been disadvantaged in that space.”
Such open conversations about sex can be valuable for raising awareness about the value of PrEP for cisgender women, who are an under prescribed population in terms of PrEP. The main option for PrEP in cisgender women is tenofovir/emtricitabine (TDF/FTC), and long acting cabotegravir (Apretude; ViiV Healthcare). But there remains much more work to be done in educating this population regarding the benefit of PrEP for them.
“Only about 5% of cisgender women that were indicated for PrEP were prescribed it back in 2017, and we only went up to 10% in 2020. So not a great number. But again, it comes down to awareness,” Mills said. “About less than 25% knew the purpose of PrEP for them as cisgender women. That persistence challenge that we see in men, we also see that in women as well. Mistrust of the medical system is [also] definitely something that continues to permeate.”
Another concern for the population of cisgender women who are indicated for PrEP is the concern of intimate partner violence. Some of these individuals who may be indicated for PrEP are concerned that if their partner found out, it may increase the risk for violence, according to Mills. This leads many ciswomen who are indicated for PrEP to decide to not start it because of these concerns for their safety.
One working group in particular has developed some positive messaging that worked to better educate and engage cisgender woman on the value of PrEP, Mills explained. This group calls it their Risk to Reason initiative, and they focus on cultural humility, which they define as the lifelong process of self-reflection and critique of not only one’s own knowledge of another’s culture, but also their own examination of their implicit biases, beliefs, and cultural identities.
“Some of the things that they've done in terms of their prevention messaging is trying to remove that word ‘risk’ and focusing more on both environment and empowerment,” Mills said. “So instead of ‘women at risk for HIV’ it’s ‘women with reasons for HIV prevention.’ This is another way of talking about it or putting this into this picture of self-care so that taking care of your whole self also includes sexual health, not just physical and mental as well, and having that be something that they deserve to also have as part of their self-care routine.”
Another effective messaging tool for this population is the idea of prevention helping to put their minds at ease and let them explore their own sexuality safely and on their terms. This messaging can be reinforced with sex positive language that doesn’t shame cis women for being sexually active or having multiple sex partners, but instead supports the importance of having knowledge around the risk versus benefit of PrEP and the value of feeling more empowered and safe.
“If they are having multiple sex partners or if they're in commercial sex work, whatever it is, it is important to not shame them being in that space. [Then] they'll be more comfortable engaging in those discussions to be on PrEP,” Mills said.
For ciswomen or those with female reproductive sex organs, concerns around being on PrEP while pregnant or breastfeeding is also a concern that may be raised, according to Mills.
“In terms of lactation, we don't see in studies that there's any significant passing into the breast milk, and there are no significant changes in pregnancy outcomes,” Mills said. “So that's another opportunity that we can provide [information] if that ends up being a concern for someone who's eligible for PrEP but doesn't want to go on PrEP for that [reason].”
Mills AR. HIV Update. Presented at: APhA 2023 Annual Meeting & Exposition in Phoenix, AZ; March 26, 2023.