Recognizing that many college students are in the riskiest category, agewise, for HIV, new guidelines aim to help providers be more proactive about PrEP.
As it becomes more widely known and acknowledged that pre-exposure prophylaxis (PrEP) is a valuable tool in the HIV-fighting arsenal, college and university health centers provide some of the best opportunities to raise awareness. Statistics from the US Centers for Disease Control and Prevention (CDC) indicate that young adults and adolescents bear a disproportionate share of new HIV diagnoses, with 21% of new infections in 2016 occurring in people between the ages of 13 and 24. Eighty-one percent of those were between 20 and 24, which translates to prime college years.
Recognizing the need for HIV prevention education in this population, the American College Health Association recently issued new guidelines, HIV Pre-Exposure Prophylaxis. The guidelines provide an overview of HIV statistics, details about PrEP and how to prescribe it, and a road map for opening up discussions with students and initiating testing and ongoing monitoring in those deemed at risk.
The guidelines came to be in part because of a recognized need on campuses. “ACHA members in several colleges saw PrEP as a compelling and urgent need, and submitted programs about it at regional and national meetings,” Margaret Higham, MD, medical director of health service at Tufts University in Medford, Massachusetts and chair of the ACHA PrEP in College Health Task Force, told Contagion®. “These presentations led to some lively conversations. The ACHA Board of Directors realized the imperative and proactively charted the creation of a task force to develop a position statement and guidelines for the use of PrEP in the college health setting.”
Unfortunately, too many providers are not being proactive when it comes to PrEP and their at-risk patients. The ACHA guidelines hope to change that by encouraging college health providers to talk about PrEP during medical visits and not wait for students to bring it up. They stress that any student who seeks testing for sexually transmitted infections is a good candidate to receive information about PrEP. If STI testing is positive, that’s a clear indication that discussion of PrEP is warranted, as STIs are known to be a risk factor for the transmission of HIV.
Another issue that the guidelines address is the lower rates of retention in HIV care seen in young people. This is due to a variety of factors, including financial barriers and transportation difficulties. If a student is prescribed PrEP, clinicians are urged to reach out early in the treatment course to ask if there are any questions or problems, and to issue reminders before follow-up appointments for HIV testing. If possible, schools are encouraged to offer walk-in appointments. The guidelines also inform schools that economically disadvantaged students can take advantage of the Gilead Advancing Access program created by Gilead Sciences, which manufactures emtricitabine/tenofovir disoproxil fumarate (Truvada) for PrEP. As of August 2018, any patient who registers with the program and demonstrates financial need is eligible to receive up to $7,200 per year in credit toward copays or deductibles.
Because students who attend college away from home may run into difficulties staying in care if they leave campus for the summer, the ACHA guidelines suggest that providers offer a 4-month supply and help students arrange HIV testing at a more convenient location. Those results can then be sent to the college. The provider also may consider making a temporary exception to the every-3-months testing protocol now in place.
The ACHA hopes that discussions about PrEP will become routine at a growing number of campuses. “In our presentations and conversations, we hear of more and more health services starting to provide PrEP,” said Dr. Higham. “But we are more likely to hear about adopters than resisters for obvious reasons. I don’t think all schools will ever offer PrEP. After all, all schools do not provide contraceptives--think of faith-based institutions, or very small schools [that] sometimes don’t even have a prescriber as part of their health service. But I do think it likely that many more schools will develop comfort and skill [with PrEP] over the coming years.”