Incorporating Preexposure Prophylaxis Into Routine Reproductive Health Care

In the study by Henny et al 1 in this month’s issue of the journal (see page 1083), preexposure prophylaxis prescription was determined among Medicaid-insured and privately insured patients who tested positive for sexually transmitted infections (STIs). Tenofovir disoproxil fumarate and emtricitabine (marketed as Truvada in combination) is the only medication currently approved by the U.S. Food and Drug Administration for preexposure prophylaxis for persons at risk for human immunodeficiency virus (HIV) infection through receptive vaginal intercourse. Preexposure prophylaxis has been demonstrated to decrease HIV acquisition in those at risk by up to 90% when taken appropriately.2,3 Preexposure prophylaxis is recommended for any person at risk for HIV acquisition, including those that have tested positive for gonorrhea or syphilis in the previous 6 months.4,5 The only contraindications to preexposure prophylaxis are HIV infection and creatinine clearance of less than 60 mL/min. It is safe to use during conception, pregnancy, and breastfeeding.6 Despite its proven efficacy and safety, rates of preexposure prophylaxis prescription rates are extremely low among at-risk women (estimates range from 2% to 6% for eligible women) and particularly among women of color.7–9 Further disparities exist by race, ethnicity, insurance type, and geographic location. Black and Hispanic women, women with Medicaid insurance or the Children’s Health Insurance Program, and women who live in the southern United States are prescribed preexposure prophylaxis less often, despite increased incidence of HIV diagnoses in these groups.10 Disparities are also worsening over time, with increases in preexposure prophylaxis prescriptions for women growing only 5% between 2012 and 2017, compared with 68% for men.7 Consistent with previous studies, preexposure prophylaxis prescription was painfully low in this cohort (less than 0.5%) among all women tested for HIV, and it was never prescribed among the more than 13,000 women who tested positive for gonorrhea or syphilis. We know from an abundance of research that preexposure prophylaxis is an important and relatively simple strategy to decrease HIV acquisition. This important question then remains, why does preexposure prophylaxis uptake remain so low, especially for women and women of color? There are three important issues about preexposure prophylaxis raised by this study: the research gap, the implementation gap, and the effect of systemic racism and bias. Women, although they represent a significant portion of the population who would benefit from HIV-prevention strategies, continue to be excluded from research. Much focus on research into barriers and implementation interventions for preexposure prophylaxis have focused on men who have sex with men and transgender women. This issue is exemplified by persons exposed to HIV through receptive vaginal intercourse being excluded from the recent initial DISCOVER See related article on page 1083.