We asked minoritized patients how they would feel if their doctor offered them an HIV test during their regularly scheduled visit. The overwhelming sentiment was that they would be offended. Why? They know not all patients are being offered an HIV test and therefore would feel profiled as a good candidate among all the patients seen during the day. We know marital status does not protect against HIV, and neither does age. And, despite some subpopulations having a disproportionate exposure to HIV, we need to normalize sexual health as health. This is why it is imperative that we screen and test all sexually active groups over the age of 13 annually for HIV and PrEP. Screening conversations should include a discussion of sexual history and HIV testing status. These conversations will determine if an HIV test is necessary. If the test comes back positive, the patient should be offered treatment immediately and connected to care. If the test comes back negative, the patient should either be introduced to (or refamiliarized with) PrEP as the most effective way other than abstinence to prevent HIV. We are working on the Two in One educational intervention to provide clinicians with the tools to screen and test for HIV and COVID, as well as policymakers with recommendations to update current guidelines.
Disproportionate screening
Due to time restraints on clinicians and stigma around HIV and PrEP, minoritized groups are disproportionately screened for PrEP medications. Former CDC guidelines from 2017 delineated the specific groups to be screened for PrEP. These guidelines stated that all sexually active individuals should be screened at least once in their lives, while “sexually active gay, bisexual, and other men who have sex with men, should be rescreened at least annually”. Although the updated CDC guidelines no longer state that these specific groups should be perceived as a high exposure group, the old guidelines still have long-lasting effects. By prioritizing these groups, individuals of other groups who also may be exposed may fall through the cracks. In 2022, about 22% of new HIV infections came from heterosexual contact. Beyond this, Black individuals have HIV infection rates seven times higher than white individuals, and Black women have rates twenty times higher than white women. However, these individuals face many barriers to being prescribed PrEP: non-inclusive marketing, clinicians who are not aware of PrEP and who it is indicated for, and clinicians who are cautious about prescribing PrEP to these specific individuals. To combat this, it is important that all patients who are sexually active are screened, regardless of their age, marital status, sexual orientation, or other social identities.
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Battling pill fatigue and stigma
PrEP is a medication that is used to prevent HIV. When taken consistently, PrEP reduces the risk of acquiring HIV by about 99%. Currently, there are four FDA-approved PrEP medications: two oral tablet options and two injection options. Both of the oral tablets are a combination of drugs that are taken as one tablet every day. One injectable medication known as Cabotegravir (CAB) is given every two months. This past June, the FDA approved another injectable medication known as Lenacapavir (LEN) to be given every six months. This new option for PrEP can greatly reduce the current stigma that is experienced with HIV prophylaxis. For many years, stigma has existed among clinicians who can prescribe PrEP and among patients who meet the requirements to take it. Part of the stigma around PrEP is potentially being seen taking a daily pill. Taking a daily medication can also contribute to pill fatigue– the exhaustion that comes with taking oral medications. By offering LEN or CAB, we can reduce both pill fatigue and the stigma surrounding PrEP among patients.
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Unclear current screening timeline
Although the current CDC guidelines state to screen for PrEP during a sexual and substance use disorder history, they are not clear on how often that should be. Previous guidelines stated that most individuals only need to be screened once in their lifetime. However, even these guidelines are not clear about when this should be done. Currently, primary care clinicians are severely overburdened. High patient volumes, increasing administrative tasks, and excessive inbox management have all contributed to the high burnout amongst workforce shortages. The vagueness of the current CDC guidelines puts more pressure on primary clinicians to fulfill more tasks within a patient visit than is possible. For this reason, it is important to specify when and how often patients should be screened for PrEP. We suggest that patients be screened at least annually. The PrEP screening conversation fits naturally in the sexual history of an annual wellness visit. Screening annually takes the pressure off clinicians during acute care visits and follow-up visits where time is limited, while also providing a clear time period when PrEP screening and education can be achieved for every patient.
There should not be shame and stigma at the doctor’s office surrounding HIV and PrEP. We are working with national partners to update our specific policy gaps and recommendations to reflect the new screening guidelines for PrEP. Clinicians should use these recommendations and guidelines to appropriately screen all patients above the age of 13 annually for HIV and PrEP.
Written by Luciana Bowden and Maranda C. Ward, Ed.D, MPH
