Talk with cisgender women about HIV risk and PrEP
By Melinda Young
Cisgender women sometimes are left out of the provider-patient conversations when it comes to discussing their risk of human immunodeficiency virus (HIV) infection and how pre-exposure prophylaxis (PrEP) can make them safer, a new paper finds.1
“One of the biggest challenges is there are not many providers who have a wealth of knowledge when it comes to PrEP,” says Keosha T. Bond, EdD, MPH, CHES, an assistant medical professor in the department of community health and social medicine at the City University of New York School of Medicine in New York, NY.
The American College of Obstetricians and Gynecologists (ACOG) reaffirmed its practice advisory regarding the use of PrEP for prevention of HIV in May 2024. It was updated in 2022 and first published in 2014.2
The advisory says OB/GYNs have an important role in increasing awareness of PrEP in their sexually active patients and for use among patients at substantial risk of HIV infection.2
As ACOG notes, heterosexual cisgender women account for 16% of new HIV diagnoses in the United States, according to 2019 data. But only one in 10 of women at risk of HIV infection received a prescription for PrEP.2
The problem involves clinicians who lack knowledge about HIV and PrEP, as well as their discomfort with prescribing the medication and stigma around its use, ACOG states.2
“ACOG has issued statements about supportive PrEP use and wellness, but it’s about the adoption of this practice — do providers actually feel they need to know this information or need to provide this medication?” Bond says.
The unfortunate truth is that OB/GYNs are practicing in a society where patients have to inform their doctors of their needs even when physicians — and not patients — should be the experts, she adds.
“We still put that burden on the patient instead of providing them with education and knowledge,” Bond adds. “PrEP is not for everybody, but everyone should be PrEP literate, and providers should make sure they know about it.”
For example, cisgender women using PrEP need to know that the drug works differently in their bodies than in cisgender male bodies. Oral PrEP takes longer to become effective in cisgender female bodies. Also, PrEP prevents HIV but not any other sexually transmitted infection (STI).
“With anal tissue, it’s effective within seven days,” Bond says. “For vaginal tissue, it takes up to 21 days.”
Biological factors have an impact on how it is used. While it still is highly effective at preventing HIV infection, female patients would need to be advised to adhere to other precautions, such as using condoms, for at least three weeks after starting a PrEP regimen.
Other factors also affect women’s use of PrEP. “At the societal and community level, there is a lot of stigma associated with taking PrEP,” Bond says. “In trials conducted in different countries, stigma played a big factor in why women did not adhere to the medication.”
Another barrier to PrEP adherence among women is because of their roles in society. They often are the caregivers and the ones in charge of contraception. They look after others’ health and may ignore their own.
“Providers need to be educated and have enough knowledge to inform their patients about PrEP,” Bond says.
It is up to reproductive and sexual health clinicians to break through the stereotypes — perpetuated by PrEP marketing — that PrEP is only for gay men. Such narrow marketing focus has excluded many people who could benefit from PrEP and resulted in a low uptake of the drug, she adds.
“We should follow the new Centers for Disease Control and Prevention (CDC) guidelines and bring up PrEP to anyone who is sexually active or thinking about being sexually active,” Bond suggests.
“We treat HIV and STIs differently from other sexual health topics,” she adds. “This should be part of our routine care, and providers can be a strong advocate for destigmatizing PrEP and other HIV prevention methods like HIV screening.”
Patients should not have to ask their doctor for HIV testing or for information or access to PrEP. Their clinicians should offer these as a routine part of care for everyone who is sexually active — not just those who are in a perceived high-risk group.
Suggesting HIV screening and PrEP only to patients the physician perceives are at risk creates stigma and labels people unnecessarily.
“When I go for my physical, there are certain tests they do, and HIV screening should be part of that routine,” Bond says. “It should be
automatic.”
Another barrier to PrEP is the cost for patients in states that did not expand their Medicaid programs.
In 2019, the Affordable Care Act (ACA) classified PrEP as a crucial tool in fighting the acquired immunodeficiency syndrome (AIDS) epidemic and classified PrEP as an effective preventive service. Insurance companies were required to cover the expense by January 2021. Later, it was amended by the U.S. Department of Labor to state that patients should not be charged for medical services related to a PrEP prescription. States that expanded Medicaid under the ACA could help defray the costs of PrEP, according to Bond’s paper.1
While many uninsured women are eligible for insurance coverage but are not enrolled, there were 1 million women in 2020 who were in the Medicaid coverage gap as a result of states not expanding Medicaid coverage. They could not access PrEP for free or at a reduced rate.1
So, insurance coverage of PrEP is a barrier for many women. Another barrier is the burden of having to take another pill once a day.
This burden could be lessened by a new version of PrEP that involves an intramuscular injection in the buttocks once every two months. Approved by the Food and Drug Administration in 2021, this newest medication is injectable cabotegravir for PrEP, and research shows it is highly effective at protecting people from HIV.3
Studies showed the injection to be safe and effective for cisgender men, women, and transgender women. The second injection is one month after the first and then every two months after the second injection.3
“Going in six times a year to get an injection is less stressful for some people than having to remember to take your medication every day, especially if you’re managing childcare, elderly care, work, school, and all the things that most women are not given credit for dealing with,” Bond says.
Another way PrEP could be made more convenient for patients is through telehealth services where they could have the pill renewed remotely and have pills mailed to their homes. Right now, a telehealth option is not available for the PrEP injection, she adds.
The biggest barrier to OB/GYNs and other reproductive health providers educating their patients about PrEP and HIV risk is stigma of the disease, and that has continued for four decades, Bond notes.
“Stigma comes from the idea that people are morally corrupt if they have HIV,” she explains.
“That has been a long-lasting stigma in our society — that HIV is this moral compass for individuals and their sexuality,” Bond adds. “And there’s an assumption that if you’re taking PrEP, you must be doing something that’s wrong when it just means you want to prevent HIV transmission.”
REFERENCES
- Chory A, Bond K. Access to PrEP and other sexual health services for cisgender women in the United States: A review of state policy and Medicaid expansion. Front Public Health 2024;12:1360349.
- American College of Obstetricians and Gynecologists. Preexposure prophylaxis for the prevention of human immunodeficiency virus. June 2022; reaffirmed in May 2024. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2022/06/preexposure-prophylaxis-for-the-prevention-of-human-immunodeficiency-virus
- Injectable cabotegravir for PrEP. PrEPWatch. Updated: July 19, 2024. https://www.prepwatch.org/products/injectable-cab-for-prep/
