Over the past 30 years, prevention efforts have helped to dramatically reduce the rate of HIV infections in the United States.1-5 At the height of the epidemic, in 1985, 130,000 new infections were reported.5
That number declined to 41,000 by 2010.2 Since 2013, however, the number of new cases per year has held steady at around 39,000 per year (38,739 in 2017),1-4 prompting the Centers for Disease Control and Prevention (CDC) to conclude that “progress in HIV prevention has stalled.”2,3
In a February 2019 report, the CDC said that the decline in new cases has plateaued “because effective HIV prevention and treatment are not adequately reaching those who would benefit most from them.”4
This article describes the populations at high risk for HIV infection and reports the results of a collaborative, multifaceted educational intervention designed to reduce the documented disparities related to HIV care
and prevention. The overarching goal of the curriculum was improving the ability of primary care clinicians to identify individuals at high risk for infection and to implement evidence-based strategies for prevention.
Populations at Greatest Risk
Black/African American and Hispanic/Latino populations in the United States are disproportionately affected by HIV. In 2017, 43% of all new infections were among Black/African Americans, even though they represent just 13% of the population.1,2 Hispanics/Latinos accounted for 26% of all new infections in 2017 but just 18% of the population.1,2 Women accounted for approximately 19% of all new HIV infections in 2017; black women represented 62% of these new infections.1,2
While overall HIV infection rates in the United States have stabilized in recent years, they have remained highest among men who have sex with men (MSM), who represent about 4% of the US population6,7 but account for 76% of new HIV infections in men and 63% of all new infections (Figure 1).1,2 CDC researchers, reviewing data from 2009 to 2013, projected that 1 in 6 MSM would be diagnosed with HIV in their lifetime, including 1 in 2 black MSM, 1 in 4 Latino MSM, and 1 in 11 white MSM.8
Figure 1. New HIV infections in the United States, 2017.1,2
A substantial portion of HIV infections occur among young MSM — defined as adolescents and young adults 13 to 24 years of age. In 2016, for example, young MSM accounted for 25% of new HIV infections among all MSM, and young black MSM accounted for 35% of new HIV infections among black MSM.3,4 Young MSM are often subjected to bullying, harassment, family disapproval, social isolation, and sexual violence, leading to poor self-esteem, emotional distress, suicide attempts, substance use, and risky sexual behavior.9
Overall, HIV infection rates among white MSM have declined in recent years, while rates have remained stable among black MSM and have increased among Hispanic/Latino MSM.1,2 Young black and Hispanic/Latino MSM are also less likely to receive adequate information about HIV prevention services or to receive pre-exposure prophylaxis (PrEP) than young white MSM.10-12 These minority groups also tend to have lower rates of adherence to antiretroviral therapy (ART).12
MSM are one of 5 “key populations” identified by the World Health Organization (WHO) who are disproportionately affected by HIV, stemming from specific high-risk behaviors as well as “legal and social barriers that further increase their vulnerability.”13 Key populations, according to WHO, also include people who inject drugs (accounting for 6% of new HIV infections in the US in 2017),1 people in prisons and other closed settings, sex workers, and transgender people.13
The rate of HIV infection among transgender individuals in the United States (1.4%) is nearly 5 times higher than the proportion of people living with HIV across the entire US population (0.3%), according to the 2015 US Transgender Survey, based on responses from 27,715 transgender individuals nationwide.14 Rates of HIV infection were higher among transgender women (3.4%), especially black transgender women (19%), as well as American Indian (4.6%) and Latina (4.4%) transgender women.14
Persistent Barriers to Optimal Care
These data support the need for effective HIV prevention and treatment programs for populations at high risk. A number of prevention measures are supported by a growing body of evidence,15-17 including:
- Suppression of viral load in HIV-positive persons through the use of ART, also known as “Treatment as Prevention” (TasP)15,16,18,19
- Post-exposure prophylaxis (PEP), effective if taken within 72 hours of a known HIV exposure,20 and
- Pre-exposure prophylaxis, or PrEP, designed for use by individuals with confirmed HIV-negative status.15-17, 21-23 (See box, Evidence-based Strategies for HIV Prevention.)
Evidence-Based Strategies for Preventing HIV Infection
Antiretroviral therapy (ART)
Early initiation of ART to reduce viral load in people who are HIV-positive significantly reduces the chances of transmission to people who are HIV-negative.15,17,18,19 The 2016 PARTNER study in 14 European countries obtained data from 548 heterosexual and 340 MSM couples who reported having condomless sex. One partner was HIV-positive and taking ART and the other partner was HIV-negative. At a mean follow-up of 1.3 years per couple, there were no documented cases of within-couple transmission of HIV.19 The Centers for Disease Control and Prevention (CDC) notes that “people with HIV who take HIV medicine as prescribed and keep an undetectable viral load (or stay virally suppressed) have effectively no risk of transmitting HIV to their HIV-negative sexual partners.”15
Post-exposure prophylaxis (PEP)
Post-exposure prophylaxis (PEP) typically follows a CDC guideline-recommended 28-day course of 1 pill containing both tenofovir disoproxil fumarate (TDF) 300 mg and emtricitabine (FTC) 200 mg once daily plus either raltegravir 400 mg twice daily or dolutegravir 50 mg once daily.20 An alternative regimen for otherwise healthy adolescents and adults consists of TDF 300 mg/FTC 200 mg once daily plus darunavir 800 mg and ritonavir 100 mg once daily. Either regimen is intended to be started as soon as possible (within 72 hours) after a high-risk exposure. Post-exposure prophylaxis is not recommended if care is sought more than 72 hours after a potential HIV exposure. Afterward, an individual is retested for HIV at 4 to 6 weeks, 3 months, and 6 months after exposure.20
PrEP is a pharmacologic intervention that has shown great efficacy in preventing HIV infection.It is a fixed-dose regimen of 1 pill per day that contains 2 HIV medications, TDF and FTC, commonly known as Truvada.23 It is intended for use in individuals with confirmed HIV-negative status and is contraindicated in those who are HIV-positive or whose HIV status is unknown.23 HIV status must be confirmed every 3 months after beginning the regimen. The drug was approved for PrEP in 2012 after 2 large randomized, double-blind, placebo-controlled trials demonstrated its efficacy.21,22
One of the pivotal studies, iPrEX, evaluated PrEP among 2499 MSM and transgender women who have sex with men, all of whom reported high-risk sexual behaviors. Over the course of 4237 person-years, the use of PrEP resulted in a 42% reduction in the risk of HIV seroconversion compared with placebo.21 The other key study was the Partners PrEP study, which focused on 4758 serodifferent heterosexual couples in Kenya and Uganda. Based on 7827 person-years of follow-up, the risk reduction for PrEP compared to placebo was 75%.22 In both studies, efficacy was strongly correlated with adherence, based on post hoc analyses of plasma drug levels in 10% of study subjects.21,22
Current FDA approval is for once-daily administration of the medication. An alternative strategy is to take PrEP “on demand” — ie, before and after sexual activity rather than on a daily basis. A double-blind, randomized, placebo-controlled trial, ANRS IPERGAY, provides support for this method to be highly efficacious in HIV prevention for MSM. The authors calculated an 86% reduction in the risk of HIV infection.46
PrEP (daily oral tenofovir) has also been reported to reduce the risk of HIV infection by 49% (vs placebo) in a trial among more than 2400 injecting drug users in Thailand.47
A CDC initiative announced in February 2019 highlights 4 areas of strategic focus, with a goal of reducing HIV infections by 90% over the next decade4: (1) diagnosing HIV as early as possible, before disease has advanced, thus accelerating the timing of TasP,24 (2) treating HIV rapidly and effectively to achieve sustained viral suppression, (3) protecting people at risk for HIV through PrEP and other preventive approaches, and (4) responding rapidly to growing HIV clusters to stop new infections.4
A number of challenges may impede the implementation of these services. One of the main challenges is identifying patients who are likely to benefit from these interventions. Another is to overcome barriers in daily clinical practice, which are primarily related to the availability and accessibility of HIV prevention services.11
Availability refers to whether or not services exist at all within a given locale.11 Typically, underserved areas do not have adequate services available to them, including education on behavioral strategies (eg, low-risk sexual activities and condom usage) and pharmacologic interventions, such as TasP, PEP, and PrEP.11
Accessibility refers to the extent to which one is able to obtain HIV prevention services when they are available.11
One of the greatest barriers in patient access to adequate HIV prevention services is poor cultural competence among healthcare providers.25-30 Language barriers, for example, can prevent high-risk individuals from asking about prevention services and can impede clinicians from providing information about, and access to, those services.11 A limited understanding of individuals who are in sexually abusive/coercive relationships and domestic settings, reside in prisons or detention centers, and/or suffer from substance use and/or mental illness may also create barriers to adequate access and adherence to HIV prevention services.
The inability to handle potentially sensitive information about individuals from different cultures can negatively affect a relationship between a patient and a provider. Providers may not know how to approach questions related to sexual relationships and behaviors; drug and substance use; and economic, social, psychological, and cultural issues that may have an impact on HIV risk and access to prevention services.
Access to healthcare and preventive services is also hampered if providers are not aware of, or fully knowledgeable about, prevention options available in the community. For example, the CDC reported in 2015 that 1 in 3 primary care physicians and nurses were not aware that PrEP existed.31
PrEP: Concerns and Controversies
PrEP is a pharmacologic intervention that, according to the CDC, can lower the risk of sexually acquired HIV by more than 90% and the risk of acquiring HIV from injection drug use by more than 70%.17,31 PrEP is a fixed-dose regimen of 1 pill per day that contains 2 HIV medications: tenofovir disoproxil fumarate (TDF) 300 mg and emtricitabine (FTC) 200 mg. The drug, approved for prevention of sexually acquired HIV infection in 2012, is intended for use in individuals with confirmed HIV-negative status and is contraindicated in those who are HIV-positive or those whose HIV status is unknown.23
Disparities in PrEP uptake and in receiving adequate information about PrEP are prominent in black and Latino young MSM communities. In 2015, approximately 500,000 African Americans and nearly 300,000 Latinos across the country could have potentially benefited from PrEP, based on CDC clinical guidelines.32 However, only 7000 prescriptions were filled at retail pharmacies or mail order services for African Americans and only 7600 for Latinos during a similar time period (September 2015-August 2016). While data on race and ethnicity were not available for one-third of the prescription data, the CDC’s analysis found “substantial unmet need” for HIV prevention.32 In a study conducted in Chicago and Houston between 2014 and 2016 among 394 young MSM (16-29 years of age), 12.2% of participants reported ever taking PrEP, but the figures ranged widely, from 29.5% of white to 11.7% of Hispanic to just 4.7% of young black MSM.33
Misinformation and misconceptions among potential PrEP users, prescribers, and in the community can exacerbate existing barriers to uptake and implementation in populations at highest risk for HIV infection.11,34 One survey of 160 gay and bisexual men who were potential PrEP candidates identified 2 main categories of negative stereotypes against PrEP. The first asserts that PrEP users are actually HIV-positive and are lying about their status. The second assumes that PrEP users are promiscuous and do not want to use condoms.34 Some studies have shown insignificant associations between the use of PrEP and increased sexual risk behavior or acquisition of sexually transmitted infections (STIs).35-38 In one study, participants reported “a sense of relief or reprieve from HIV-related stress … a sense of security and less free-floating fear of HIV” that did not necessarily lead to condomless sex.35 A number of more recent studies, however, have reported an increase in the occurrence of bacterial STIs (such as chlamydia, gonorrhea, and syphilis) in people taking PrEP,39-42 suggesting “a need to reinforce counseling and STI diagnosis and treatment efforts” for patients who pursue this course of therapy.39
IMPACT: An Educational Intervention
To help expand HIV prevention practices to underserved populations at increased risk of HIV infection, Haymarket Medical Education led the development of the HIV Prevention Collaborative, active from 2017 to the present. The aim of the collaborative was to build on the CDC’s HIV prevention efforts and draw upon the collective expertise of national organizations that are dedicated to serving black and Latino communities, and experienced in educating these populations on HIV prevention strategies. Members of the collaborative included the American Medical Association, Health HIV, National Coalition for LGBT Health, Morehouse School of Medicine, National Area Health Education Centers (AHEC) Organization, National Hispanic Medical Association, National Medical Association, Urban Health Plan, and Advancing Knowledge in Healthcare (AKH Inc.).
The collaborative partners designed and implemented a CME/CE-certified, sequenced learning initiative known as IMPACT on Health Disparities in HIV Prevention (the acronym stands for Identification, Mitigating risk, PrEP/PEP, Awareness, Condoms, Testing). The initiative developed multiple educational interventions targeting primary care clinicians across the United States who regularly see patients with a high lifetime risk for HIV infection, particularly young MSM of color.
The overarching goal of the educational curriculum was to improve the ability of primary care clinicians to identify individuals likely to benefit from HIV prevention strategies and provide them with access to interventions in a manner that takes into consideration the stigma, socioeconomic issues, and cultural factors that frequently pose significant barriers to the uptake of services.
The IMPACT curriculum consisted of 7 live and online activities, ranging from a national satellite symposium to regional webinars and local workshops:
- A half-day executive summit meeting titled, The Need for HIV Prevention in Diverse Populations: Eliminating Health Disparities, involving representatives from all partners in the collaborative. An e-monograph was published based on the proceedings of this gathering.
- A 2-hour satellite symposium on State-of-the-Art Strategies for HIV Prevention in the LGBTQ Community, presented at SYNChronicity, the 2017 annual meeting of HealthHIV and the National Coalition for LGBT Health. To extend the reach of the program, a webcast of the live event was posted online at myCME.
- A 2-hour satellite symposium at the annual meeting of the National Hispanic Medical Association, Stand Up to HIV: Prevention Strategies for Your Community, offering case-based learning focused on cultural competence and HIV prevention needs in the Hispanic population. A webcast of the proceedings was posted for online learners, along with a case study.
- Three live, 1-hour, case-based national webinars coordinated by the National Medical Association, the National Coalition for LGBT Health, and the National AHEC Organization.
- Five online clinical cases with HIV patients (African American, LGBTQ, Hispanic, Native American, Alaska Native) that provided learners with exposure to patients’ perspectives on HIV prevention.
- Two live, 1-hour workshops on HIV prevention for primary care clinicians at the Morehouse School of Medicine in Atlanta, Georgia, co-sponsored by Morehouse and the Urban Health Plan.
- A 2-hour satellite symposium, Ending HIV: Family Physicians on the Front Line of Prevention, with case-based learning that addressed specific responsibilities of the family physician, held at the Family Medicine Experience (the annual meeting of the American Academy of Family Physicians), followed by an enduring webcast of the symposium and an enduring online case.
After completing each activity, individuals were required to complete a multiple-choice post-test pertaining to the activity and to submit a program evaluation. These surveys collected data on self-reported improvement in knowledge and competence as well as planned practice changes and projected patient benefit. Learners were also asked to identify anticipated barriers to practice change and any additional education they felt they needed to improve their HIV prevention efforts. Eight weeks after the completion of each activity, participants were emailed a follow-up survey asking them to document the specific changes they had made to their practice after participating in the education and what benefits to their patients they observed as a result.
In total, 21,615 clinicians have participated in at least 1 online CME/CE activity, and 11,787 clinicians have claimed continuing education credit for at least 1 activity. Learners include MDs and DOs, physician assistants, nurse practitioners, nurses, and other healthcare professionals. A total of 790 clinicians attended the in-person activities.
Analysis of outcomes data reveals overall significant improvements in clinician knowledge, competence, and practice. Learners were assessed via a baseline pretest, with the same questions asked after completion of each activity. Learners showed meaningful increases in knowledge and competence of key teaching points, with notable rates of improvement from pre-test to post-test — a 104% aggregate improvement in knowledge and a 130% improvement in responses to the competence questions (Figure 2). Although physicians had marginally higher baseline test scores than other professionals, similar rates of improvement were seen across all professional categories. Learners also demonstrated an 87% improvement in knowledge related to the learning objectives, from 47.1% pre-test to 87.9% post-test, based on data gathered from all live and enduring activities.
Figure 2. Increase in knowledge and competence of key teaching points.
The proportion of learners who reported being “very knowledgeable” about evidence-based guidelines for HIV prevention, including the use of PrEP in individuals at risk for infection, increased from 25% at baseline to nearly 68% at the conclusion of the activity. Similarly, the percentage who felt “not at all” knowledgeable about HIV prevention guidelines decreased from 28% pre-activity to 2% post-activity (Figure 3).
Figure 3. Knowledge assessment question results.
The majority of participants in all activities reported that they had gained confidence in their ability to identify patients who are appropriate candidates for HIV prevention strategies, utilize HIV prevention interventions in patients at risk, and employ culturally competent education and HIV prevention counseling strategies.
At baseline, just over half of learners said they provided PrEP or referred patients to sources where they could obtain it; after participating in an IMPACT activity, nearly 90% said they would prescribe PrEP or refer for it. The proportion who said they would not do either dropped from approximately one-fourth of the participants to less than 3%. Notably, the number of learners who said that prescribing PrEP is not relevant to their practice dropped from nearly 20% to less than 8% (Figure 4).
Figure 4. Competence question results.
Changes Made in Practice
Learners were asked 8 weeks after the activity whether they had made changes in their practice following their participation in the IMPACT program.
- The percentage who said they always or often identify patients who are appropriate candidates for HIV prevention strategies doubled, from 33% prior to the activity to 66% at the time of the outcomes survey.
- The percentage who said they make use of HIV prevention strategies in patients at risk nearly doubled, from 37% preactivity to 70% later.
- The percentage who said they employ culturally competent education and HIV prevention counseling strategies for individuals at risk rose from 37% preactivity to 68% (Figure 5).
Figure 5. Reported changes in practice following participation in the IMPACT program.
To determine the patient-level impact of the activity, learners were asked via a postevaluation survey how many patients on average they see each day; how many days per week, on average, they see patients; and what percentage of the patients they treat are at risk for HIV infection. Analysis of these data indicates that the education has the potential to have an impact of 22 patients at risk for HIV infection per participant, per week (Figure 6).
Figure 6. Patient-level impact of the activity.
When asked at the 8-week follow-up survey to define the positive results that the education had on patient outcomes, participant responses included:
- Can take good sexual history and identify patients at risk
- Exceptional counseling and education to patients at risk for HIV
- Excellent improvements in identifying patients who are appropriate candidates for HIV prevention strategies
- Higher utilization of PrEP
- I feel more confident talking to patients and helping them feel more comfortable taking about issues related to HIV and sexual health
- Patients are more receptive; I am confident counseling patients on the subject
Findings from specific CME/CE activities included the following:
- A monograph educating participants was distributed in conjunction with the curriculum. The percentage of learners who knew that MSM bear the heaviest burden of HIV infection increased from 71% prior to the release of the monograph to 93% following the release. Additionally, the proportion who knew that adherence to PrEP among young MSM dropped off fastest among young black MSM increased from 65% to 95%.
- After the satellite symposium at SYNChronicity, the proportion of learners who could state the correct level of risk reduction associated with 5 daily doses of PrEP increased from 44% to 93%. The percentage who said they would provide PrEP to appropriate patients, or refer patients to resources where they might be able to obtain it, increased from 65% to 83%. At the beginning of the activity, 48% reported they would educate patients about appropriate HIV prevention strategies; at the end, 64% said they would do so.
- Following the satellite symposium at the annual meeting of the National Hispanic Medical Association, the percentage of participants who knew that follow-up visits for patients taking PrEP, based on CDC recommendations, should occur every 3 months increased from 57% to 97%.
- Learners also demonstrated improvement in their understanding that patients’ needs for safer sexual practices and for intimacy with their partners were the principal reasons for adherence to the PrEP regimen (25.7% pre-test vs 88.6% post-test).
Need for Further Education
The educational curriculum of the IMPACT initiative addressed gaps and disparities in HIV infection rates and prevention services, identified barriers to care, and outlined evidence-based strategies for prevention. While these teachings resulted in measurable improvements in participants’ knowledge, competence, and practice, there remains a need for further education as barriers to optimal practice persist.
In the aggregate analysis, 80% of learners acknowledged the need to make changes in their practice, but 6 months later 24% said they still didn’t have enough knowledge to make those changes. Approximately 34% said that patient adherence had proved to be a barrier; 28% cited a lack of time and resources to consider making changes; and 27% identified insurance, reimbursement, or legal issues as substantial challenges.
On average, at the conclusion of the activities, half of the participants said they were “very comfortable” discussing sexual health issues with their patients. Some concerns about PrEP remain: the possible development of resistant HIV strains and less frequent use of condoms or other safer sexual practices in patients taking PrEP.
Next Steps for Improving HIV Prevention
Applying the learnings and eliminating disparities in access to HIV prevention services involves talking candidly and comfortably about HIV with patients, assessing the individual’s risk for infection, discussing available prevention methods, and prescribing or referring as appropriate.11 Assessing HIV risk requires conversations about sensitive topics (ie, sexuality, drug use) with patients who may be reticent to discuss such information. Clinicians can help by taking measures to eliminate stigma and facilitate relationships that can normalize discussions about sexual activity and its consequences. To begin, clinicians should ask their patients if they have had sex within the past 12 months. If so, follow-up questions can include how many partners they had sex with, the gender(s) of their partners, and in what type(s) of sexual behavior did they engage. The CDC has published a guide to taking a sexual history43 and a set of specific instructions for taking a sexual history from transgender people.44
Other questions may include the role of the influence of alcohol on recent sexual encounters, the use of drugs to get high before or during sex, condom use/nonuse, and whether patients had been in a detention center, jail, or prison for more than 24 hours during the last 12 months. Clinicians can delve further into questions about alcohol, tobacco, and other substance use in the recent past, whether use led to legal or financial trouble, whether a friend or relative expressed concern about substance use, and if patients have tried without success to curtail their substance use. Notably, no additional financial resources are required to make sure patients are asked about sex; drugs; and social, economic, cultural, and psychological issues that may affect HIV risk and access to HIV prevention and treatment services.
Targeting barriers related to the availability and access of HIV prevention and treatment services can help eliminate disparities. To do so, it is important to combat the stigma linked to societal and cultural factors associated with HIV and to increase cultural competence and patient literacy. For example, providers can learn basic medical Spanish to help improve clinician-patient relationships in Hispanic/Latino communities. Using tools for health literacy, providing outreach, and engaging in community-specific messaging to patients in various languages may also improve these relationships. Cultural competence has been associated with “higher quality of care, better patient self-management, and better health outcomes among minority patients.”30
A Pivotal Role for Primary Care
Primary care physicians write the majority of prescriptions for PrEP. This makes them ideally positioned to identify individuals at risk for HIV infection and to provide HIV prevention services for these individuals. The CDC’s guidelines for PrEP, first developed in 2014 and updated twice since then, emphasize that (1) many people at very high risk for HIV infection are not getting PrEP, and (2) any prescribing healthcare provider can provide PrEP care.31,32,45 (See box, CDC Guidelines on PrEP — and Other Helpful Resources.)
Thus, it is critical that healthcare providers receive education about HIV prevention strategies and interventions for overcoming barriers to the uptake of and adherence to services. A fairly significant proportion of IMPACT learners (4%) were emergency medicine clinicians, 4% were pediatricians, and an additional 4% were obstetrician-gynecologists. Therefore, future educational activities on HIV prevention could be extended to these audiences.
From this foundation, the optimization of HIV prevention and treatment will be expanded to move closer toward the goal of eliminating disparities in HIV care.
CDC Guidelines on PrEP–and Other Helpful Resources
The CDC published guidelines on the use of HIV pre-exposure prophylaxis (PrEP) in 2014, updated them in 2017, and published the revised document online in March 2018.
PrEP Clinician Helpline: 855-448-7737 or 855-HIV-PrEP
Richard A. Elion, MD, is associate clinical professor of internal medicine at George Washington
University in Washington, DC, and medical director of CAPE. Mesfin Fransua, MD, is a professor of medicine in the Infectious Diseases Section of Morehouse School of Medicine in Atlanta, Georgia. H. Gene Stringer Jr, MD, is associateprofessor of medicine and chief of the Infectious Diseases Section of the Department of Medicine of Morehouse School of Medicine in Atlanta, Georgia. Krista Sierra, MA, is director of grant and content development at Haymarket Medical Education in Paramus, New Jersey.
Acknowledgements: The educational activities for the IMPACT curriculum were supported by unrestricted grants from Gilead Sciences Inc. Writing assistance was provided by Jeremy Pagirsky of Haymarket Medical Education.
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This article originally appeared on Clinical Advisor