Addressing the Gaps to PrEP Access

We are continuing our new series, Media Day, where we spotlight individual medical institutions and infectious disease (ID) programs. Today, we spotlight UNC’s Institute for Global Health and Infectious Diseases (IGHID).

There are a number of concerning issues and barriers associated with PrEP access including insurance limitations, stigma, logistics, and awareness. It is this last issue, awareness, and limited educational opportunities that can make a significant difference in people accessing this form of HIV prevention, according to Sarah Rutstein, MD, PhD, assistant professor of medicine at School of Medicine at UNC in the Division of Infectious Diseases. 

In her work overseas and in the US, Rutstein says one of the major differences is which sexes have been vulnerable to HIV in the US compared to Africa and specifically Malawi, a resource-depleted country.

“In the southeastern United States, we often think about men who have sex with men, and increasingly, now heterosexual women of African American descent. And historically in Malawi, the prime population that has been vulnerable to HIV has been adolescent girls and young women…To really make it clear, this is not about trying to single out one population based on whatever stereotypes or whatever sort of assumptions you're making about who they're having sex with.”

In Rutstein’s work, one of the biggest things she and colleagues have seen is that men do not engage in health care the way that women did.

“They're [men] not coming in for antenatal care or family planning, or a lot of the other ways that we engage young women in Malawi in the health care system, and therefore, get an opportunity to educate them about PrEP and HIV prevention,” Rutstein said. “Men just don't have that same access to health services. And we see the exact same thing here in the United States, where we're looking at, how do we reach people who aren't otherwise engaging in health services? And it turns out, [sexually transmitted infections] STI clinics, if you have an STI, you're going to go in and you're going to try and get it treated.”

In Malawi they integrated PrEP into one the largest urban STI clinics there. Taking that model, and applying it domestically, there were calls for applications from the National Institutes of Health to think about integrating PrEP into STI services in the US. And this seemed like an expansion of the work they had been doing in Malawi, according to Rutstein.

“I think it speaks to the unique opportunity to really take a lot of the lessons that we learned in low resource income settings like Malawi and apply them to other similarly very low resource settings here in the United States—where rural North Carolina certainly fits that bill,” Rutstein said.

While she notes that awareness and education are crucial, structural barriers are really the biggest access issues in the US today.

“It is this cost of the medication, the access to the blood tests that are needed to appropriately start," Rustein said. "So, I think comfort with providers and actually prescribing and knowing, once I prescribe it, how are they actually going to get this medication? and how do I safely counsel them about the safety of staying on or safely coming off when they perceive themselves to no longer need it?”

In the next episode, Jonathan Parr, MD, MPH, details his work on a genomic sequencing project and how it is being used to monitor drug-resistant malaria.