With a recently released issue of Pediatrics, practitioners have a great opportunity to learn about Pre-exposure Prophylaxis (PrEP) for HIV prevention among adolescents. A “State of the Art” Review by Drs. Hosek and Henry-Reid (10.1542/peds.2019-1743) is accompanied by a framing commentary on the topic by Ms. Pike and Dr. Bekker (10.1542/peds.2019-3172) from The Desmond Tutu HIV Centre, University of Cape Town, South Africa. PrEP is a pill with the brand name Truvada™ that contains two medications used to treat HIV, tenofovir and emtricitabine. PrEP is intended for anyone who is HIV-negative and at high risk of acquiring HIV, for example individuals who have a sexual partner who is HIV-positive, or who have multiple sexual partners and inconsistent condom use, or who inject drugs and share needles. PrEP is safe and effective, and has been FDA-approved for adolescents at risk for HIV since May 15th, 2018, yet prescribing and uptake are frankly inadequate. Of the 1.1 million people in the US who would benefit from PrEP, less than 20% have gotten a prescription for PrEP, and of those prescriptions, just 1.5% were for teenagers. PrEP is unfortunately a well-kept secret, about which all of us, regardless of practice location and population served, should become informed.
Speaking for myself, knowledge was patient-driven: an 18-year-old whom I had cared for since infancy arrived for a follow up visit about 4 years ago and asked me for PrEP. I must have looked as confused as I felt, since I could not figure out why an adolescent would want to engage in a Pediatrics in Review and Education Program (“my” PREP). The teen asked me if I knew about PrEP, and I responded that I did not think I did. She (I am carefully using the teen’s preferred pronoun since I knew that her birth sex was male) educated me that she was getting tested every 3 months for HIV, was HIV-negative and was “trying” to use condoms with each sexual encounter, but had several partners, of whom one was HIV-positive. She had learned about PrEP from friends and wanted to use it. I listened, read, prescribed and (successfully) fought for the pre-authorization. She explained she would obtain refills as soon as she got into Transition Clinic, a specialized gender-affirming clinic that supports the process of “transitioning,” i.e. changing one’s external appearance to align with the gender one feels internally.
This State of the Art Review and accompanying Commentary emphasize that the “path” to prescribing PrEP begins with frank but confidential conversations with teens about sexuality and sexual practices. Without confidentiality, the authors emphasize, building trust is near impossible. Universal HIV screening is another must, and is recommended for all teens by age 16-18 years, with more frequent screening if risk factors are present. Finally, the authors recommend we talk about the value of PrEP for HIV prevention with the parents/guardians of teens at risk – PrEP does not replace condom use but few know it is safe and works. The authors present data whose impact should galvanize us into action: 21% of new HIV diagnoses in the US (2017) were among those ages 13-24 years, yet less than 10% of teens report having been tested for HIV, and an estimated 44% of US teens living with HIV do not know they are infected. We have work to do! This excellent State of the Art Review is a great place to begin learning, and check out the link here for additional information about PrEP and educational resources that patients and families can use.