WHEP Scholar Alexandra Forrest
Drexel University College of Medicine, Class of 2019
Pre-exposure prophylaxis (PrEP) is a medication regimen that is used to protect at-risk populations from HIV infection. The FDA approved the drug TRUVADA (emtricitabine/tenofovir) in 2012 to reduce the risk of HIV acquisition following the publication of several landmark trials that established its efficacy. TRUVADA is taken as one pill once a day and can reduce the risk of acquiring HIV by over 90% [4]. The Centers for Disease Control and Prevention (CDC) recommends PrEP use among women with a known HIV positive sexual partner, a recent bacterial STI, multiple sexual partners, inconsistent or no condom use, those living in areas with high HIV prevalence, and those who are commercial sex workers. Despite these recommendations and its approval over 5 years ago, PrEP use has been limited among women.
Men who have sex with men (MSM) are traditionally the focus of HIV research; however, statistics suggest that, worldwide, women may be at higher risk for HIV acquisition than men. Young women ages 15-24 are two times more likely to be at risk for HIV infection than their male counterparts. Moreover, worldwide, HIV is the leading cause of death among women ages 15-44. The high risk in women is frequently associated with sexual abuse and unequal power in intimate relationships. In data released by Gilead, the biopharmaceutical company that manufactures TRUVADA, only 2,491 women were using PrEP in 2015. That same year, the CDC estimated that 0.6% of women ages 18-59, or 468,000 women, had indications to use PrEP. Despite the significant global burden of HIV infection on women, data and education about PrEP use in women is limited.
In order to better understand what gender discrepancies exist in research, advertising and education about PrEP, several sources of data were identified: PubMed was used for a literature review; Gilead's website was used to analyze the ways in which PrEP is advertised; and Gilead's educational site “Help Stop The Virus,” the CDC Risk Reduction Tool, Clinical Care Options for HIV, and MedScape were examined.
Many patients and providers underestimate the risk of HIV transmission in women. This may be because it has historically been treated as a disease unique to the MSM community. Women are often not aware of their partner's risk factors for HIV, yet they are the ones at a statistically greater risk for transmission in the setting of unprotected vaginal intercourse. While appropriate education materials about PrEP exist, most require self-initiated study. Overall, it seems as though adequate education material about PrEP for women is available but the translation of this information into clinical practice has not occurred.
PrEP marketing appears somewhat biased towards men, which is consistent with the gender discrepancies that also exist in research and education. The TRUVADA webpage markets PrEP for individuals of all genders, sexual orientations and races. The “Help Stop the Virus” website run by Gilead, however, uses mainly male imagery. This skewed representation can inappropriately signal to women that they are not at risk for contracting HIV. Moreover, it can make it difficult for women to envision themselves taking PrEP and may contribute to some of the stigma that already exists surrounding HIV testing and prevention.
Individuals within the HIV research community have also noticed the PrEP gender discrepancy. A 2017 review article about women and PrEP written by Bailey et al. stated that, “Research to date has been heavily focused on the high-risk men who have sex with men population, yet, many women worldwide remain at high risk of HIV transmission.” It is clear that these biases are starting to garner national attention. Identification of this incongruity is the first of many steps in equalizing gender differences and improving HIV prevention for all individuals.
Future Directions
There are several ways in which the research about PrEP for women could be improved. Barriers to adherence deserve further investigation in order to identify if this is in fact affecting the outcomes of studies about PrEP. Identification of these barriers could also help to improve implementation of PrEP in at-risk groups of women. Furthermore, it is important for research to be conducted in a variety of settings composed of a diverse group of women. Specifically, it is essential to incorporate women at risk of transmission through both sex and IV drug abuse and to incorporate women in parts of the world outside of Africa in order to represent the full spectrum of women who qualify for PrEP. I believe that these specific changes will help to create a more robust source of literature about PrEP use in women.
Education materials about PrEP seem adequate; however, this information needs to be further disseminated. A specific important investigation is about how PrEP is being communicated about between individuals and within communities. Sexual counseling is notoriously a difficult issue to discuss and the burden of initiating this conversation often falls on patients. It is therefore possible that a large group of individuals who would benefit from PrEP are being missed simply because information is not being disseminated and these sensitive discussions are not taking place. PrEP should be marketed as an HIV prevention method for individuals with any of the many risk factors for HIV acquisition. At present, the advertising seems to be more focused on the MSM community. With better education about the risks faced by women may come better advertising to women about PrEP.
Cost may remain a significant barrier to accessing PrEP for some individuals. If women are reliant on their partners for financial support, then this could prevent them from accessing PrEP. Moreover, women who are victims of sexual abuse or who are in relationships of unequal power are known to receive less preventative care than men, and therefore likely are not being identified by providers as being at risk for HIV transmission. There should be specific outreach to these vulnerable individuals in order to provide them with PrEP in a discrete manner.
Differences in PrEP research, education, and marketing clearly exist between genders. The first step to address this is identifying ways in which the gap can be reduced. PrEP is a tool that has the potential to provide significant change in the public health domain.