Can Moving HIV Medicine Into Primary Care Reduce Stigma?

Kerry Dooley Young

August 19, 2022

Integrating HIV prevention and treatment into primary care could help address the persisting stigma about the virus, which is keeping some patients from getting access to drugs that can prevent infection, researchers say.

The reconsideration of separate healthcare sites, times or days, or specialized personnel for HIV prevention and care is a key way clinicians may be able to reduce stigma and reach more patients, say authors of a recent paper in the July 2022 Journal of the International AIDS Society.

In their paper, co-authors Sarit A. Golub, PhD, MPH, and Rachel A. Fikslin, PhD, both of Hunter College, New York, note that several studies conducted in sub-Saharan Africa showed that the integration of HIV care into primary healthcare improved patients' willingness to accept HIV services, increased HIV care enrollment, and increased client HIV care sustainment over time.

Navigating "care without being labelled by people in their community as having HIV" could "lessen the experiences of discrimination and give people more control over disclosure," Golub and Fikslin write.

But there are challenges to making such a shift.

The paper also calls for a new look at the clinical protocols associated with HIV preexposure prophylaxis (PrEP), especially given the "widespread recognition that frequent appointment requirements for HIV care and quarterly refill requirements for PrEP are extremely burdensome."

In an interview with Medscape Medical News, Golub also noted a general discomfort among physicians about asking questions about people's intimate experiences.

"The main barrier to integration of HIV into primary care is the fact that we don't actually often integrate sexual health into primary care," Golub told Medscape in an interview. "There are still large numbers of primary care providers who don't feel comfortable talking about sexual health with their patients."

Increasing PrEP Use

The same rethinking of HIV service implementation is part of broad efforts underway to increase use of PrEP in the United States to reach more people who could protect themselves from HIV.

An influential US panel is updating its recommendations about PrEP, with an emphasis on questions about the effectiveness of integrating this medicine more into primary care.

Among the questions posed by the US Preventive Services Task Force (USPSTF) for its current reevaluation of its PrEP recommendations are:

  • What are rates of adherence to PrEP and factors associated with increased or decreased adherence in US primary care settings?

  • What factors (such as race and ethnicity, age, sex/gender/sexual orientation, HIV risk category, socioeconomic status, cultural factors, educational attainment, or health literacy) are associated with disparities in utilization of PrEP?

  • What is the effectiveness of primary care interventions to reduce disparities in utilization of PrEP?

The current USPSTF recommendation on PrEP, issued in 2019, gives a top mark, an "A" grade, for clinicians offering PrEP with effective antiretroviral therapy to people who are at high risk of getting HIV. No care setting is mentioned in the recommendation itself. But USPSTF notes in the accompanying text the challenges of identifying persons who are at risk for HIV because of stigma, discrimination, or lack of trust between patient and clinician.

Last year, the Centers for Disease Control and Prevention (CDC) recommended that clinicians inform all sexually active adults and adolescents about PrEP. The CDC PrEP guidelines are straightforward, putting prescribing of these medicines "well within the scope of practice for all primary care clinicians," Christopher M. Bositis, MD, said in a July Medscape webinar.

"As many as 1.2 million people in the United States have some indication for PrEP use," said Bositis, a family physician and HIV specialist at the Greater Lawrence Family Health Center in Massachusetts. "Unfortunately, not everybody who could benefit is actually taking it."

In an email exchange with Medscape Medical News about the recent paper from Golub and Fikslin, Jessica Jaiswal, PhD MPH, of the University of Alabama, agreed with the need to integrate HIV prevention more in primary care but also noted some of the challenges. These include a lack of resources in clinics that work with underserved and marginalized people. There are still misunderstandings about who can prescribe PrEP, she wrote.

"Integrating HIV prevention in primary care settings is absolutely possible - and should be the goal - but structural constraints really limit healthcare providers' ability to do this," Jaiswal wrote.

"We often point to clinicians' lack of knowledge around HIV prevention (eg, PrEP) or their lack of cultural sensitivity, but it's important to acknowledge that healthcare providers aren't generally set up for success in this area, especially in primary care settings," she said.

Arguments for, Against Algorithms

Some researchers have sought to use algorithms to make it easier for clinicians to reach patients who can benefit from PrEP. That's a practice Golub and Fikslin criticize in their paper.

"The concept of 'high-risk' behaviors, individuals or populations evokes powerful stereotypes, which have consistently fueled prejudice and discrimination within healthcare settings," they write.

But Douglas Krakower, MD, of Beth Israel Deaconess Medical Center, is among those who see potential benefits in algorithms, especially in light of efforts to integrate HIV medicine more into primary care.

In 2019, Krakower and colleagues published a paper in The Lancet HIV about their research into using electronic health records to aid in developing these kinds of algorithms for primary care. The algorithms could help clinicians reach the patients who are most likely to benefit from PrEP amid efforts to integrate counseling about this medicine more widely into US healthcare, Krakower said.

"We should be shaping the tools in a way that actually brings providers to a point where they have the training and understanding of how to do this in a way that's not stigmatizing," Krakower said.

"Our thinking is that these tools could actually accelerate the process of bringing more people into HIV preventive services, at least as we're working towards the aspirational goal of universal discussions about PrEP," he said.

In their interviews with Medscape Medical News, Golub and Krakower both complemented the other's work while spelling out differing views. They said that they have been respectfully and publicly at odds for some time about the role of algorithms in HIV medicine.

Golub said that she understands the impulse behind the aid of an algorithm in finding patients who could benefit from PrEP, given the intense demands on clinicians. But the algorithms developed to date have not been proven that accurate, carrying with them the risk of stigmatizing patients.

Those factors might make any clinician wary about using algorithms, she said. If they look carefully at the performance of algorithms and the real risk of aiding stigma, "they might actually make different choices."

Golub and Krakower both spoke for a more active role of clinicians in primary care to become more active in HIV medicine.

"If you can make this a medical condition, where people feel like they're integrated in primary care the way they would with any other condition, it would reduce stigma," Krakower said.

J Int AIDS Soc. Published online July 12, 2022. Full text

Kerry Dooley Young is a freelance journalist based in Miami Beach, Florida. She is the core topic leader on patient safety issues for the Association of Health Care Journalists. Follow her on Twitter at @kdooleyyoung

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