The Benefits of HIV PrEP for Women

In part 3 of this 3-part episode, Jeffrey Kwong, DNP, MPH, ANP-BC, discusses the benefits of HIV pre-exposure prophylaxis (PrEP) for women in preventing HIV, strategies for eliminating HIV globally, knowledge gaps in the treatment of patients with HIV, and what primary care providers need to know about PrEP. 

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Listen to part 1 and part 2 of this 3-part episode.

Jeffrey Kwong, DNP, MPH, ANP-BC, is a professor in the division of advanced nursing practice at Rutgers School of Nursing (Newark, New Jersey). 

TRANSCRIPTION: 

Jessica Ganga: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your host Jessica Ganga with Consultant360 a multidisciplinary medical information network, along with your moderator, Jessica Bard.

About 10 percent of women who could benefit from HIV Pre-exposure prophylaxis were prescribed HIV PreP in the United States in 2019, according to the most recent data from the Centers for Disease Control and Prevention.

Here with us today to speak about HIV Pre-exposure prophylaxis is Dr Jeffrey Kwong, who is a professor in the division of advanced nursing practice at Rutgers School of Nursing. Let’s listen in.

Jessica Bard: Thank you so much for joining us on the podcast today Dr. Kwong. It's a pleasure to have you here. We're talking about HIV PrEP. Let's talk specifically about women now. There are lots of benefits to PrEP. It's private, it's user controlled. It can empower people, specifically women to protect themselves without relying on a partner's behavior. Why would you say that PrEP is so uncommon among women?

Dr Jeffrey Kwong: Great question. So that's something that is a question that public health folks have been trying to look at and HIV prevention folks have also been trying to address. Just for clarification, I should say that when we're referring to women here, we're referring in the context specifically of cisgender women. Transgender women have also a great area of need for PrEP. One that has been looked at, but I'll focus primarily here on cisgender women.

I think part of it is just concept that they may not see themselves at risk. Because people think of, oh, it's HIV, it's HIV prevention, that's "a gay disease" or a gay issue. I don't identify that way and that's not relevant to me. So I think that is the message that we need to address, or I should rather say that's the myth that we need to address, which is that it's not just for gay men. That it's not just for young people, that this is an intervention for everyone.

I think there have been efforts both at the... I know in different locals. Again, I speak from my experience in New York City, from local health departments to also at the national and federal levels to really promote PrEP among cisgender women. The American College of Obstetrics and Gynecology also endorses PrEP as an effective and preferred intervention method for HIV prevention. So we're trying to do a lot of education and breaking down of this myth or this misconception that PrEP is only for men, or it's only for gay men specifically and making this more accessible to all individuals, all genders.

The other thing I think that came up a couple of years ago was one of the second oral option for PrEP, which is Tenofovir Alafenamide and emtricitabine was primarily studied in men who have sex with men and transgender women and cisgender women were not part of that initial study. So the FDA labeling on that particular form of PrEP, it does not include individuals who are at risk through vaginal sex. So I think there was a little bit of a misstep in that study trial and the company that manufactures the drug is working on that end has started a new study. But that was one of the criticisms specifically regarding that and sort of an example of how women were excluded from some of the scientific data.

But again, hopefully we're addressing that with the injectable option that was just approved. It was studied in men who have sex with men, transgender women and specifically a whole study on cisgender women, the HPTN084 trial. So there is good data there. So there is evidence. We just need to make sure that we advertise it more.

Jessica Bard: Yeah, that's an interesting point. When we talk about the goal of eliminating HIV globally, it's unlikely that one strategy will eliminate HIV. In addition to PrEP, what strategies can actually help eliminate HIV globally?

Dr Jeffrey Kwong: Yeah. When we think about HIV elimination, especially at the global level, it is something that requires multi-level intervention. So in addition to PrEP, the other key thing is testing and making sure that people A, know their HIV status, because we know that the majority of new infections occur in people who are unaware of their HIV status and unknowingly are transmitting HIV to others. So testing folks and making sure universal opt out testing is part of generally accepted practices, which the USPSTF, US Preventative Services Task Force does recommend universal testing as well. So that's one way.

The other thing that is important to help eliminate HIV is making sure that people who have HIV are on treatment and are taking their medications regularly. Because we know with the current medications that we have available, people with an undetectable viral load are doing very well and it also prevents transmission to others. So again, that's another way that we can help end the epidemic is just by making sure that people living with HIV are on treatment and have ongoing viral suppression with the use of the antivirals that we have available.

So I think a combination of all of those methods is great and making sure that people have access to clean syringes, if they engage in injection drug use. Making sure that there are syringe exchange programs and accessible options there to prevent bloodborne transmission through shared injection drug use equipment.

Jessica Bard: To your earlier point, including cisgender women in studies, what knowledge gaps exist in the treatment of patients with HIV and the prevention of HIV?

Dr Jeffrey Kwong: Great. So yes, women for sure and one of the areas that I am particularly interested in is in HIV and aging. Actually I had to do this other presentation fairly recently looking at specifically use of PrEP in older adults. Needless to say, there is a lack of data in use of preexposure prophylaxis in older adults. I think when we think about a population that's at risk for HIV, although we think and we know that the majority of new infections occur in younger adults, about a quarter of new HIV infections occur in people over 50. We know that STI rates are high in older adults 60 and over because many of them, again, don't think that they're at risk for STIs. They don't necessarily use barrier methods if they're engaging in vaginal or anal sex.

So that's a population that I think could and should benefit from PrEP, but we just don't have enough data. We use it, we prescribe it, I still use it in patients. I think my oldest patient on PrEP is in his mid seventies at the moment and it's working well for him. But I would say that moving forward for newer options that are available, that I think we need to really look at that population as well.

Jessica Bard: What do infectious disease clinicians need to know about PrEP and as well as primary care providers?

Dr Jeffrey Kwong: In terms of from an ID perspective, I think this is something that I think hopefully most ID specialists are aware of and feel fairly comfortable managing. But I think this is a thing where the ID folks can really be the champions and help educate their primary care providers or primary care colleagues to focus on. I mean, I think in certain settings where there are not a lot of resources or where the ID folks are overburdened with other ID issues, this is something that primary care providers can easily manage.

Once you get a patient started on PrEP, it's pretty straightforward to manage. So I think primary care providers would be surprised at how easy it is to manage and I think ID folks can help just to train and educate their colleagues on that.

Jessica Bard: Great. Well, thank you so much for joining us on the podcast today. We really appreciate your time.

Dr Jeffrey Kwong: Well, thank you for having me.