By Shivesh Shourya Shivesh (he/him) is a third year Neuroscience major who is also pursuing a minor in Society and Genetics at UCLA. Shivesh is passionate to learn about the intersection of behavioral sciences and society’s relationship with biomedical research and innovation. He is particularly interested in advocating for the LGBTQ+ community, working towards de-stigmatizing HIV/AIDS, and learning about how public policy shapes access to essential medicines. While he is originally from Texas, Shivesh currently lives in New Jersey with his family. In his free time, Shivesh likes to cook/bake, listen to music (his favorite artist is Taylor Swift), and do calligraphy. He is a huge proponent of his chocolate-strawberry flavored smoothie and plain Cheerios. Truvada, more commonly known as pre-exposure prophylaxis (PrEP), was first approved by the FDA in 2012. Manufactured by Gilead, this blue pill significantly reduces the risk of transmission of the human immunodeficiency virus (HIV), if taken daily. Truvada is a combination of nucleoside analog HIV-1 reverse transcriptase inhibitors, meaning that it effectively blocks HIV replication within the body.
In 2017, preliminary data showed that gay, bisexual, and other men who have sex with men (MSM) accounted for 67% of new diagnoses of HIV infection. Within HIV incidence statistics, Black and Latinx MSM were seen to be disproportionately affected as rates among Black and Latinx MSM were 10.5 and 4.9 times higher than the rate among White MSM, respectively. Data gathered from 2017 indicated that approximately one third of gay, bisexual, and other men who have sex with men (MSM) reported using PrEP. Given PrEP’s 99% efficacy, one would expect to see high rates of PrEP use and adherence within communities that are affected by increased exposure to HIV. However, Black and Latinx MSM were significantly less likely than White MSM to be aware of PrEP, to have discussed PrEP with a health care provider, or to have used PrEP within the past year. Among those who had discussed PrEP with a health care provider within the past year, White MSM had the highest reported PrEP use. These statistics highlight obvious racial/ethnic health disparities that are exacerbated by social and structural factors. PrEP’s patent, which was filed by Gilead, has only recently expired. While a new generic drug replacement for Truvada has been approved by the FDA, it is yet to be released in the market. Gilead has moved quickly to maximize their profits by patenting a new drug, Descovy, which has similar active ingredients as Truvada but minimal side effects. Both Truvada and Descovery, which are FDA approved and available on the market for PrEP, cost an upwards of $1800 with health insurance. With no cheap alternatives currently available for PrEP, low PrEP use could be associated with challenges of cost and affordability. The CDC reports that PrEP use among those without health insurance was relatively low across all racial/ethnic subgroups. However, the disparity between White and Black users of PrEP still persisted among MSM with health insurance suggesting that racial minorities face additional challenges in access to PrEP aside from costs. PrEP use is also heavily stigmatized as it is perceived by many as a medication specific to gay men and an indicator of promiscuity. This exacerbates an individual’s anxiety around being judged or “outed” by members of society. Current public health research and media discourse on PrEP has largely centered on PrEP use by MSM due to their disproportionate risk for contracting HIV; however, this focus inadvertently perpetuates the idea that PrEP is a medication specific to MSM and lowers PrEP use by individuals in heterosexual relationships with a seropositive partner. Research suggests that Black and Latinx MSM perceive greater stigma about PrEP compared to their White counterparts, as they have a greater concern about people noticing and making assumptions about their PrEP use. As stated above, racial disparities in PrEP use persist among groups that are educated or made aware of PrEP, calling for an analysis of provider or practitioner attitudes. Healthcare providers play a central role in disseminating preventative medical information because of their medical training and access to resources associated with this goal. In a 2017 study, providers reported several barriers to prescribing PrEP, some of which included difficulty determining eligibility and time demands associated with adherence/follow-up monitoring. However, preliminary evidence suggested that many of these challenges were often overestimated due to non-standardized approaches to PrEP prescription in clinical settings, limiting access for some individuals and promoting inequities. Interim PrEP prescription guidelines issued by the CDC and WHO allow for provider subjectivity in a patient’s suitability for PrEP. According to the CDC, potential PrEP recipients should be at an ongoing high risk for acquiring or being exposed to HIV, but the CDC provides few examples. With lacking specific eligibility criteria and the reliance on provider discretion, variabilities in PrEP prescription practices are likely to be based on inherent biases and stereotypes. At the center of the issue is risk compensation analysis. Risk compensation is sometimes referred to as behavioral disinhibition, and in the context of PrEP, sexual risk compensation would refer to reduced condom use, having more partners, etc., all of which are based on the assumption that PrEP has lowered the individual’s likelihood of acquiring HIV. This in turn reduces a provider’s willingness to prescribe PrEP. It is important to note that current behavioral analysis studies have shown that there are no significant differences between sexual compensation behavior of randomized groups of PrEP users and non-users. Racial disparities also tie into risk compensation. Historically rooted stereotypes of Black men as sexually uninhibited and irresponsible influence provider attitudes and make them less receptive to prescribing PrEP to Black MSM. Currently, there is no empirical support for the stated stereotypes, but nonetheless, they can influence PrEP prescription rates and usage statistics. Patient risk analysis heavily relies on patient self-reports which may not be accurately disclosed for a multitude of reasons, including discomfort with sharing sensitive information and fear of provider judgment. Black MSM in particular may be uncomfortable in disclosing their sexual behavior because of anticipated or internalized heterosexism and racism, and the fear of “outing,” contributing to the racial disparity. Given these glaring racial inequities and the role that healthcare providers play in perpetuating them, health justice advocates have called for routinization of PrEP provision in clinical settings to increase provider cultural competence and reduce medical mistrust. Routinization of PrEP in annual check-ups ensures that information about PrEP is provided to all patients who stand to benefit and not just those at perceived higher risks. It empowers the patient to make their own choice and sets precedent for standardized procedures for PrEP prescriptions. While affordability still remains an issue, the release of generic PrEP into the market should help improve accessibility. Current activist groups such as PrEP4all have continued to work tirelessly to increase PrEP accessibility and combat inequities in PrEP use. Planned Parenthood, local LGBTQ+ resource centers, and other community funded programs remain a key point of distribution of PrEP and HIV testing. It is crucial that taxpayer funding be invested in these programs to ensure equitable access to PrEP for every patient who stands to benefit. The American healthcare system has continued to pathologize and police queer bodies and BIPOC in an effort to publicly humiliate and profit off of the lives of these individuals. PrEP is a biomedical innovation like no other and lies at the intersection of progress and retrogression. Given the structural and social barriers that still remain in accessing PrEP, healthcare professionals must take the initiative to challenge social norms and big pharmaceutical companies such as Gilead to break down barriers and ensure equitable access to PrEP and other preventative care.
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