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This article was written from an interview with Dr. Rachel Scott, MD, MPH.
In 2021, 36,136 people in the U.S. were diagnosed with HIV. While that annual number declined 12% between 2017 and 2021, there is opportunity to do more—particularly among women and members of historically marginalized populations.
Medications called pre-exposure prophylaxis (PrEP) can significantly reduce the risk of acquiring HIV. When used correctly, they reduce the risk of contracting HIV from sexual contact by up to 99% and from intravenous drug use by at least 75%.
The challenge is to get PrEP to the patients who need it. Despite its effectiveness, data from the U.S. Centers for Disease Control and Prevention suggest that only about 30% of the 1.2 million people who could benefit from this antiviral medication got a prescription for it in 2021.
There are many reasons why PrEP isn’t widely prescribed. Part of the barrier is the historic focus on prevention for men, specifically men who have sex with men, leaving women out of marketing efforts.
This is part of the reason why HIV rates among heterosexual women remains high. In 2021, 16% of people with new infections were women who reported heterosexual contact. Only 6% were heterosexual men.
Here in Washington, DC, HIV continues to be an epidemic. According to the latest data from DC Health, nearly 12,000 District residents are living with HIV. Disparities including education, poverty, and other social determinants of health also have a significant impact on HIV transmission rates and access to prevention methods. HIV affects underrepresented groups at a higher rate. Black Americans make up 40% of HIV infections despite accounting for just 12% of the population. Among women diagnosed in 2019, Black women made up 54% of cases.
National and global efforts to wipe out another pandemic have been effective recently. If our society can mobilize against COVID-19, surely we can work together to move beyond HIV’s 40-year legacy of devastation.
MedStar Health programs such as Safe Babies Safe Moms are connecting more patients to PrEP and working to understand the barriers that prevent people, especially women, from taking advantage of the protection it can provide.
Stigma is an obstacle to PrEP access.
In my work with DC-area women with HIV, most of my patients were in monogamous relationships when they acquired HIV. These are women with one sexual partner, but because they live here in DC where about 1.8% of the population is living with HIV, their risk is much higher than among women in other parts of the country.
Despite this, our society tends to put the blame on individuals with HIV for contracting the disease, because of behaviors like unprotected sex or sharing HIV needles. Our research has found this stigma harms prevention efforts because people who could benefit from PrEP don’t want to be perceived as irresponsible or promiscuous. It’s important that we work to destigmatize HIV so more people can access safe, effective prevention methods.
Neighborhood impacts on HIV transmission.
While personal behaviors can increase the risk of acquiring HIV, research shows that where someone lives is at least as important as their behaviors. Studies have shown that HIV rates are higher in communities confronting poverty.
U.S. data from 2016 and 2017 shows that most new HIV infections are concentrated in specific geographic areas. More than half of all new diagnoses during that time occurred in just 48 counties, plus San Juan, Puerto Rico and Washington, DC. Research indicates that a significant factor is the high prevalence of HIV in these areas, which leads to increased transmission.
How to reduce the risk of HIV transmission.
There are more ways than ever to prevent HIV transmission during sex, but they’re not all created equal. For those who are sexually active, the two primary methods are barrier prevention and PrEP.
Barrier prevention (condoms).
Condoms, when used correctly and consistently, are effective at preventing HIV, some other sexually transmitted infections (STIs), and pregnancy. Condoms work by stopping the exchange of bodily fluids with a thin layer of latex, plastic, or natural materials. They come in two varieties:
- External use (male condom): 90% effective against HIV transmission
- Internal (female condom): Up to 94% effective against HIV transmission
Of course, condoms only work if sex partners agree to use them. There are religious and political stigmas, and condoms require sexual partners to negotiate before sex. For people who want to control HIV exposure regardless of a partner’s preferences, there’s another option.
Pharmacological prevention (PrEP).
PrEP means using medicine to reduce the risk of contracting HIV. PrEP provides up to 100% protection against HIV and allows patients to enjoy their sex lives with less worry about HIV acquisition. This can be very empowering for patients, improving their quality of life.
PrEP works by stopping HIV from taking hold and spreading in the body. A combination of two antiretroviral drugs supports the body’s immune system and prevents the virus from replicating in healthy cells.
The U.S. Food and Drug administration has approved two pills (Truvada and Descovy) and one injection (Apretude) for use as PrEP. Not every medication is approved for everyone, so talk with your health care provider about which might be right for you. They can help you determine your risk of contracting HIV and discuss the best methods to help you stay healthy.
PrEP does not provide protection against HIV until the medicine builds up in your body. This means you need to take it for a while before it’s effective–-a few days for men and about three weeks for women. Certain PrEP medications may have side effects such as diarrhea, nausea, headache, and fatigue. These usually go away over time.
PrEP is safe and effective for most patients, regardless of their gender or sexual identity. PrEP is even safe for most pregnant people to use. Truvada, the daily pill version of PreP, has been shown to be safe and effective for both mother and fetus. I always talk to my patients individually to discuss the side effects of oral PrEP, because more stomach upset can be especially difficult during the first weeks of pregnancy and it’s important to weigh the known benefits of the medication against the risks.
In our clinic here at MedStar Washington Hospital Center, the D.C. Safe Babies Safe Moms Program is working hard to help DC mothers stay healthy and live their best lives. All the providers in our clinic are comfortable discussing and prescribing PrEP to our patients because we know it can often make a major difference in their lives.
PrEP does not prevent other STIs or pregnancy. However, research is underway on a version of PrEP that protects against HIV and prevents pregnancy.
Related reading: Six Things to Know About HIV and Testing.
PrEP offers an effective, discreet way for patients to take control of their health, and ending stigmas may be our biggest opportunity when it comes to reducing HIV transmission. To increase the number of people on PrEP, providers must understand its benefits and help patients feel comfortable about discussing sex in realistic terms of prevention.