Preventive Medicine 113 (2018) 122–123
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Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Discussion
Medical students reflect on the future of Pre-Exposure Prophylaxis use among adolescents and young adults
T
Ivie Eweka, Jean Fleuriscar, Jacqueline Fleuriscar1, Adenike Adeyemi-Jones, Brianna Dillon, ⁎ Tashuna Albritton City University of New York (CUNY) School of Medicine, City College of New York, 160 Convent Avenue, New York, NY 10031, United States
A R T I C LE I N FO Keywords: Pre-Exposure Prophylaxis HIV Adolescent Prevention
Imagine a world in which HIV/AIDS no longer decimated populations. As medical students, that is the world we envision with the increased use of Pre-Exposure Prophylaxis (PrEP). PrEP is a recent HIV prevention method for individuals who do not have HIV but are at a high risk for infection. This method includes taking a daily pill comprised of a combination of drugs, traditionally used to treat HIV, to lower the chances of becoming infected even after exposure to the virus (Baeten et al., 2013). Clinical trials have shown the biological effectiveness of PrEP among adherent individuals. Bisexual and gay men and men and women in HIV discordant relationships with detectable levels of tenofovir have shown 92% and 90% reductions in risk of HIV, respectively (Grant et al., 2010; Baeten et al., 2012). For people who inject drugs, efficacy was 74% among those with detectable tenofovir concentrations (Choopanya et al., 2013). Given these findings, we understand the importance of PrEP intervention and its potential impact in the U.S. and other nations. As we strive to help build healthy communities through primary preventative care, we want to see PrEP use implemented across high-risk populations, including among adolescents and young adults. Ultimately, prevention is key. However, only 3% of the national budget for HIV/AIDS is allocated for domestic prevention while 61% covers care and treatment (U.S. Federal Funding for HIV/AIDS, 2017). That HIV/AIDS prevention funds remain flat is troubling and costly. A paradigm in which prevention is emphasized will subsequently reduce treatment expenditures. More importantly, it will prevent high risk individuals from ever contracting the disease—and should that not be our main objective? To avoid illness and promote wellness? A well-
⁎
known aphorism states, “an ounce of prevention is worth a pound of cure.” We are optimistic that PrEP use will expand to include younger high risk groups soon. Youth, especially those in underrepresented minority groups, are disproportionately affected by HIV/AIDS. In 2014, adolescents and young adults aged 13–24 years accounted for an estimated 22% of all new HIV diagnoses in the United States (Center for Disease Control, 2015). Similar to adults, young people engage in sexual practices that put them at increased risk for HIV and other sexually transmitted diseases. In 2015, the Youth Risk Behavior Surveillance System indicated that 30% of U.S. high school students had sexual encounters during the previous 3 months and, of these, 43% did not use a condom at their last sexual encounter; furthermore, 21% reported drinking alcohol or using drugs before their last sexual encounter (Center for Disease Control, 2016). These behaviors put young populations at risk for HIV, yet only 10% of sexually experienced students reported ever being tested for HIV (Center for Disease Control, 2016). Making PrEP widely available can significantly reduce new HIV diagnoses among adolescents and young adults, but there are barriers to accessing the drug. One barrier is the ambiguity in guideline language among federal health administration agencies, such as the U.S. Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) regarding the safety of PrEP use in younger populations (U.S. Department of Health and Human Services U.S. Food and Drug Administration, 2012; Center for Disease Control and Prevention, 2014). In 2012, the FDA approved PrEP in combination with safer sex practices to reduce the risk of sexually acquired HIV-infection among
Corresponding author. Jacqueline Fleuriscar is presently at the New York Medical College, 40 Sunshine Cottage Rd., Valhalla, New York 10595, United States. E-mail addresses:
[email protected] (I. Eweka), jfl
[email protected] (J. Fleuriscar), jfl
[email protected] (J. Fleuriscar),
[email protected] (A. Adeyemi-Jones),
[email protected] (B. Dillon),
[email protected] (T. Albritton). 1
https://doi.org/10.1016/j.ypmed.2018.05.020 Received 6 July 2017; Received in revised form 18 May 2018; Accepted 21 May 2018 Available online 22 May 2018 0091-7435/ © 2018 Elsevier Inc. All rights reserved.
Preventive Medicine 113 (2018) 122–123
I. Eweka et al.
very limited number of adolescents are currently being introduced to oral PrEP, testing adherence to other PrEP modalities may prove difficult. To conclude, we hope for a thorough, yet speedy resolution as to who should receive PrEP and when. We know that PrEP is one of the most important biomedical advances to emerge in the fight against HIV/AIDS, and stands alone as an effective form of chemoprophylactic prevention. We continue to promote safe sex through condom use and believe that together these two methods can significantly reduce HIV incidence. Making PrEP available to the most vulnerable populations is vital, and creating universal guidelines for use among adolescents and young adults across health systems is needed. Also, we must be vigilant in increasing patient and provider awareness and in assessing attitudes toward use and implementation that affect PrEP use. As future physicians, we want to practice medicine in a U.S. healthcare system that enables us to provide the best preventive measures for patients of all ages in protecting against HIV.
high risk adults. The drug is already used to treat HIV infection in adults and children ages 12 and older (U.S. Department of Health and Human Services U.S. Food and Drug Administration, 2012). However, guidelines neither recommend nor discourage providers from prescribing PrEP as an HIV prevention method for youth aged 12 and older. In 2014, the CDC released clinical guidelines for the use of PrEP, which state that “currently the data on the efficacy and safety of PrEP for adolescents are insufficient. Therefore, the risks and benefits of PrEP for adolescents should be weighed carefully in the context of local laws and regulations about autonomy in health care decision-making by minors” (Center for Disease Control and Prevention, 2014). The agency maintains its permissive stance but also acknowledges the lack of clarity in the FDA's guidelines (Center for Disease Control and Prevention, 2017). We are concerned that these ambiguities will heighten provider discomfort in prescribing PrEP to younger populations. However, a recent study published from the Adolescent Medicine Trials Network for HIV/AIDS Interventions could be the turning point needed to reshape the discussion regarding PrEP use among those under age 18. The study indicated that adolescent men who have sex men (MSM), aged 15 to 17 years, showed no adverse events known to be associated with PrEP use (i.e., renal events, elevated serum creatinine levels, bone fractures) (Hosek et al., 2017). These findings give us hope that future studies will reflect similar results. Meanwhile, because of the benefits to using PrEP, some highly affected metropolitan areas in the U.S. have adapted more lenient guidelines. For example, New York City recommends that PrEP be offered to adolescents at high risk for HIV infection. These recommendations however emphasize that providers adhere to appropriate warnings due to limited data and to consult institutional policies regarding parental consent when administering PrEP (New York State Department of Health (NYSDOH), 2015). A second barrier to PrEP use in younger populations is the uncertainty of drug adherence. Among non-daily adherent clinical trial participants, there was a 44% reduction in incidence among MSM; (Preexposure Prophylaxis Initiative) and a 75% relative risk reduction in heterosexual individuals when evaluating efficacy (Partners Preexposure Prophylaxis Study) (Grant et al., 2010; Baeten et al., 2012). Non-daily effectiveness resulted in 86% relative reduction in HIV incidence among MSM (PROUD and IPERGAY clinical trials) (McCormack et al., 2016; Molina et al., 2015). While these numbers are lower than the risk reduction when the pill is perfectly adhered to, approximately 90% reduction (Grant et al., 2010; Baeten et al., 2012) – for those who are at high risk, the impact is significant. PrEP adherence was low among young MSM (15 to 17 years old), but the feasibility for implementation in this demographic was high (Hosek et al., 2017). PrEP was believed to be very effective and acceptability was high but appropriate PrEP implementation strategies were needed to facilitate better adherence (Hosek et al., 2017). Implementation strategies will need to impact adherence barriers at the individual (e.g., HIV vulnerability and social support) and structural (e.g., financing for PrEP, youth-friendly health services, provider prescribing biases) levels, with a particular emphasis on increased contact with providers (Hosek et al., 2016). We believe that despite adherence concerns adolescents and young adults should have the same sexual and reproductive health rights as adults to benefit from PrEP; however, youth are often excluded in biomedical clinical trials (Hoffman et al., 2016). The current literature on adolescent knowledge about how PrEP works is limited. Yet we do know that older teens and young adults have reported perceived benefits and receptiveness to daily PrEP (Smith et al., 2012). If adolescent participation increases in biomedical research, the medical community will have a fuller understanding of PrEP adherence and implementation pitfalls. Scientists are exploring different ways to deliver PrEP, and these new drug delivery systems (injectable, device implantation) could be instrumental in improving adherence (Markowitz et al., 2016; Schlesinger et al., 2016). However, if a
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