Pre-exposure prophylaxis (PrEP) - 2017

How can Pre-Exposure Prophylaxis (PrEP) help in HIV prevention?

Prepared by Pamela DeCarlo and Kimberly Koester, CAPS/PRC/CHPRC Community Engagement (CE) Core | May 2017

What is PrEP?

Pre-Exposure Prophylaxis (PrEP) is an HIV prevention method for people who do not have HIV but are concerned about getting HIV. Currently, PrEP involves taking one pill (Truvada) a day on a consistent basis.[1] Clinical guidelines for PrEP recommend that people be tested for HIV and kidney function before starting medication. While on medication, people should be tested and treated for sexually transmitted infections (STIs) every 3 months, for HIV every 6 months, and for kidney function as indicated.[1] Anyone newly diagnosed with an STI or HIV should be offered treatment.

Does PrEP work?

Yes! PrEP can work to prevent transmission of HIV, when the medication is taken consistently every day. Daily PrEP reduces the risk of getting HIV from sex by more than 90%. Among people who inject drugs, it reduces the risk by more than 49%.[2] A Kaiser Permanente study followed 972 patients over 3 years and found that no HIV infections occurred among those who took PrEP; however, 2 infections occurred in individuals who stopped taking PrEP after losing health insurance coverage.[3] At Magnet, a community clinic in San Francisco, CA, there have been no new HIV infections among 1,196 patients enrolled in their PrEP program.[4] PrEP may work differently to prevent transmission through vaginal sex than through anal sex. In the iPrEX clinical trial, protection from anal transmission was achieved taking the medication 4-5 times a week.[5] A clinical trial with cisgender women found that taking the pill 6-7 times a week provided protection from vaginal transmission.[6]

Is PrEP safe?

Absolutely. Most of the people who take PrEP do not experience side effects. For those people who do, the side effects are generally mild and go away within a month. The most common side effects are nausea, digestive problems, kidney issues and bone loss. One study found that taking PrEP generally was safer than taking aspirin.[7]

How else can PrEP help?

PrEP can provide mental health benefits. Several studies and many PrEP service providers report that PrEP use appears to decrease HIV-related stress and anxiety as well as increase the potential for greater intimacy and sexual pleasure. In fact, some people stated that after starting PrEP, they were able to have sex without the fear of HIV for the first time in their lives. Others felt hope for the future and optimistic about their love lives.[8,9]

PrEP can increase self-efficacy. PrEP is the first reliable method for HIV prevention that provides people with a relatively easy way to take an active role in preventing HIV. It does not require telling, showing or negotiating with partners, and does not need to be used during sexual activity.[10]

PrEP can facilitate access to healthcare. Many PrEP programs are serving young, healthy people—populations that otherwise may not access healthcare or health insurance. Because PrEP involves frequent laboratory testing and prescription medication, programs are training PrEP navigators to help patients sign up for insurance coverage, pay for medication, find a medical provider, encourage medication and appointment adherence, and access other social services that can help with staying healthy.

How can PrEP access be improved?

Remove structural barriers. Like most medications and behavioral prevention efforts, PrEP only works if it is taken as prescribed. It appears that many people accessing PrEP are highly motivated to take the pill, and that structural issues, not individual level issues, may be bigger barriers to adherence. Some of these barriers include being unable to pay for PrEP and clinical/laboratory services, problems finding providers that will prescribe PrEP in a nonjudgmental manner, difficulty attending clinic every 3 months, as well as concerns related to having experienced and perceived HIV-related stigma.

Reduce costs. PrEP medications cost $1200 - $1500 per month. Most insurance, including Medicaid, will cover PrEP, but some insurance plans have high co-pays and out-of-pocket expenses. Changing jobs or health care plans can often result in a gap in insurance when people may not be able to afford PrEP. Some states and Gilead, manufacturer of Truvada, have medication assistance programs to help offset these costs.[11] Increase use of PrEP navigators. PrEP navigators work in a variety of public and private health care settings to connect people to PrEP services and gain access to insurance and other programs to pay for PrEP.

Increase provider comfort and knowledge. Some healthcare providers are unaware of HIV pre-exposure prophylaxis or are uncomfortable prescribing PrEP for their patients. Providers may have misconceptions about the efficacy of PrEP, or assume that their patients will not be adherent.[12] Prejudice and bias around race, gender, sexuality, age, condom use and drug use may make providers unlikely to offer and/or prescribe PrEP to some patients. One study found that providers were most willing to prescribe PrEP to MSM with an HIV+ partner, and less likely to prescribe to heterosexuals and people who inject drugs.[13]

Address health disparities. While PrEP use increased over 500% between 2013 and 2015, disparities exist. Current use only covers a small percentage all the people who could benefit from PrEP, and PrEP uptake has been low among African Americans, Latinos, women and young adults.[14]

What's being done?

There are a variety of places such as, primary care clinics, STD and HIV clinics, family planning clinics, pharmacies and websites as well as a variety of providers such as physicians, nurse practitioners and pharmacists, offering PrEP services. Many service agencies across the US have created PrEP programs to help those who want and need PrEP, with a focus on underserved communities such as Black and Latino gay men, transgender women and youth. Some of these agencies include Callen-Lorde Community Health Center, Chicago PrEP Working Group, HIVE, Philly FIGHT, and Houston Area Community Services.[15] In Seattle, WA, the Kelley-Ross community pharmacies have implemented One-Step PrEP, a program where patients can meet with a pharmacist, be screened and prescribed PrEP, get follow-up lab tests and pick up prescriptions all in one place. Kelley-Ross also helps navigate insurance, and 98% of their patients pay $0 for their medication. Several programs are delivering PrEP via telehealth, such as Nurx.com (available in 11 states). People interested in PrEP sign up on the website by answering a few key questions that are reviewed by a doctor. Clients are then directed to a local lab to seek HIV, STI and kidney testing. Once labs are reviewed by a Nurx doctor, PrEP medications are either delivered to their door or can be picked up at a local pharmacy. Because finding a provider who knows about PrEP can be challenging, three services pleasePrEPme.org, pleasePrEPme. global and PrEPlocator.org offer a directory of public and private PrEP providers. You can search for providers that accept uninsured patients and for navigation services.

What needs to be done?

When new medications are introduced to the general public, health disparities are often highlighted, as underserved populations may be unaware of, unable to access and be suspicious of new medications. PrEP presents an opportunity to address and reduce these disparities. While many healthcare providers have championed PrEP for their patients, providers also can be a major stumbling block. Successful PrEP providers are likely to engage in shared decision-making with their patients, providing accurate information about PrEP, and trust that their patients will be positioned to make the best decisions about their own health. New medications and methods for delivering and monitoring PrEP that can lower barriers to access are being developed and tested. These include new, longer-lasting medications; drugs delivered via injection, vaginal and rectal microbicides and vaginal rings; and self-screening for HIV and STIs.[16] With the changing landscape of healthcare and policy in the US, we need continued advocacy for PrEP access and funding.

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Says Who?

1. CDC. Preexposure prophylaxis for the prevention of HIV infections in the United States—2014: a clinical practice guideline. Atlanta, GA: US Department of Health and Human Services, CDC, US Public Health Service; 2014. CDC fact sheet for providers
2. CDC. PrEP 101 Consumer Info Sheet. 2016.
3. Volk JE, Marcus JL, Phengrasamy T, et al. No new HIV infections with increasing use of HIV preexposure prophylaxis in a clinical practice setting. Clin Infect Dis. 2015;61:1601-1603.
4. Gibson S, Crouch P-C, Hecht J, et al. Eliminating barriers to increase uptake of PrEP in a communitybased clinic in San Francisco. 21st International AIDS Conference. July 2016. Durban, South Africa. Abstract FRAE0104.
5. Anderson PL, Glidden DV, Liu A, et al. Emtricitabine-Tenofovir concentrations and preexposure prophylaxis efficacy in men who have sex with men. Science Trans Med. 2012:4;151-
6. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367:399-410.
7. Kojima N, Klausner JD. Is emtricitabine-tenofovir disoproxil fumarate pre-exposure prophylaxis for the prevention of human immunodeficiency virus infection safer than aspirin? Open Forum Infect Dis. 2016 Jan 6;3(1):ofv221.
8. Koester K, Amico RK, Gilmore H, et al. Risk, safety and sex among male PrEP users: time for a new understanding. Culture, Health & Sexuality. 2017.
9. Golub SA, Radix A, Hilley A, et al. Developing and implementing a PrEP demonstration/ implementation hybrid in a community-based health center. 11th International Conference on HIV Treatment and Prevention Adherence, May 9-11, 2016, Fort Lauderdale, FL. ADH9_OA409.
10. Seidman D, Weber S. Integrating PrEP for HIV prevention into women’s health care in the United States. Obstetrics and Gyn. 2016;127:37-43.
11. CDC. Paying for PrEP. 2015.
12. Elion R, Coleman M. The preexposure prophylaxis revolution: from clinical trials to routine practice: implementation view from the USA. Curr Opin HIV AIDS. 2016;11:67-73.
13. Adams LM, Balderson BH. HIV providers’ likelihood to prescribe pre-exposure prophylaxis (PrEP) for HIV prevention differs by patient type: a short report. AIDS Care. 2016;8:1154-1158.
14. Bush S, Magnuson D, Rawlings MK, et al. Racial characteristics of FTC/TDF for Pre-exposure Prophylaxis(PrEP) users in the US #265. ICAAC 2016. Boston, MA; June 16-20, 2016.
15. http://hivprepsummit.org/index.php/prepresources/
16. Mayer KH. PrEP 2016: What will it take to generate demand, increase access, and accelerate uptake? 11th International Conference on HIV Treatment and Prevention Adherence, May 2016, Fort Lauderdale, FL. ADH11.

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Special thanks to the following reviewers of this Fact Sheet: Leah Adams, Pierre Crouch, Rick Elion, Nathan Fecik, Jayne Gagliano, Barbara Green-Ajufo, Colleen Kelley, Jeffry Klausner, Daryl Mangosing, Alan McCord, Karishma Oza, Rupa Patel, Jim Pickett, Rebecca Sedillo, Dominika Seidman, Aaron Siegler, Jill Tregor, Jonathan Volk, Shannon Weber. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Many Fact Sheets are also available in Spanish.

©2017, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. 

This publication is a product of a Prevention Research Center and was supported by Cooperative Agreement Number 5U48DP004998 from the Centers for Disease Control and Prevention.