The global rollout of HIV pre-exposure prophylaxis (PrEP) is lagging in some settings, and improvements in messaging could give it an important boost.
A commentary published in The Lancet
offers recommendations for programmatic success, highlighting potential pitfalls and offering alternative approaches.
Messages should focus on what PrEP is for, rather than who it is for, and reflect the goals of sexual health, wellbeing, and safety, K. Rivet Amico, PhD, associate professor of health behavior and health education at the University of Michigan School of Public Health and an author of the commentary, told Contagion®
"When we make it really targeted it becomes really easy for people to think, 'That's not for me because of who I am,'" she said.
Because PrEP isn't a treatment for those with an infection but rather a preventive option, the focus should be shifted away from the biomedical paradigm, Linda-Gail Bekker, MBChB, DTMH, DCH, FCP(SA), PhD, told Contagion®
. Dr. Bekker, an author of the commentary, is deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine at the University of Cape Town in South Africa.
"I do think it needs a paradigm shift, but I feel like we're struggling to make that paradigm shift," Dr. Bekker said.
Dr. Amico said the idea for the commentary sprang from the 2018 International AIDS Conference in Amsterdam, the Netherlands.
"We have a unique opportunity to introduce PrEP in communities as promoting protection and wellbeing, as available to everyone, and as forming part of an investment in longevity, health, and wellness," the authors wrote in the commentary.
The commentary points out 3 main areas of concern—the sell, brand, and product placement—and noted that, under current practices, PrEP is often promoted in risk-awareness messaging, marketed to select and often stigmatized groups, and offered as a special or non-integrated service.
"We propose that the sell should focus on protection or wellness framing, the branding should convey PrEP as appropriate for anyone in need, and the provision of PrEP should be placed in the context of other relevant and valued health services," the investigators wrote in the report.
Dr. Amico said that targeted approaches to rolling out PrEP to most at-risk groups have been cost effective but come with unintended consequences.
"Inherently accessing PrEP right now automatically stigmatizes you as someone who may be engaging in high-risk sexual activity," Latesha Elopre, MD, assistant professor in the Division of Infection Diseases at the University of Alabama School of Medicine, told Contagion®
. "Just because you're accessing this tool doesn't mean you've done something wrong."
PrEP is most widely prescribed by physicians treating patients with HIV and in health departments, Dr. Elope said, adding that she would like to see it spread more widely via other medical professionals, including primary care physicians and obstetrician-gynecologist specialists.
Expanding PrEP prescribing throughout the medical community could address the purview paradox some patients seeking PrEP encounter, Christian Grov, PhD MPH, chair of the Department of Community Health and Social Sciences at the City University of New York School of Public Health and Health Policy, told Contagion®
. Some patients encounter such a paradox when primary care physicians refer them to HIV specialists, whose work focuses more on treatment of those already infected rather than prevention, Dr. Grov said.
He compared PrEP and the challenges surrounding it to oral contraception.
"A woman should not have to go to a specialist in order to get oral contraceptives," Dr. Grov told Contagion®
Efforts to improve access to PrEP have been ongoing. Recently, a team of investigators created PrEP@Home
to ease the burden on patients of ongoing follow-up visits with clinicians.
Another recent study found that those who are following the PrEP regimen maintain relatively high quality of life scores
The goal of the new commentary in The Lancet
was to raise awareness and "obviously not to tell programs that are doing a great job what they should or shouldn't be doing," Dr. Amico told Contagion®
"The perfect shouldn't be the enemy of the good," she concluded. "It's certainly not to say that we need to have a perfect system…We're not devoid of reality. We know that people are challenged and people are, in many cases, doing the very best they can."
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