In the United States, adolescents and young adults (AYA) ages 13-24 years accounted for 22% of all new HIV infections in 2014, with rates of acquisition highest (80%) among young men who have sex with men (MSM).1 People of color have a much greater lifetime risk of HIV compared to non-Hispanic whites, and data suggest that unless prevention efforts improve, 40% of black young MSM will acquire HIV by age 40.2 Stark disparities in HIV infection also exist by geographic location, where rates of HIV diagnoses among young adults in 2015 were disproportionately high in the South.3
The 2020 U.S. National HIV/AIDS Strategy (NHAS) lays out its vision: “The United States will become a place where new HIV infections are rare and when they do occur, every person regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.”4
Primary goals of the National Strategy include: reducing HIV-related disparities and health inequities and providing full access to comprehensive pre-exposure prophylaxis (PrEP) services with support for medication adherence for those using PrEP.4
PrEP Is Proven to Work
Daily use of the anti-HIV medication known as PrEP by people who are HIV-negative has demonstrated a reduction in HIV transmission rates by up to 75% in heterosexual partners and up to 99% among MSM and transgender women.5,6 Unfortunately, due to limited data among adolescents, PrEP was FDA-approved in 2012 as Truvada only for adults ages 18 years and older.
In the first open-label study to examine the safety, adherence, tolerability, and changes in sexual risk behavior among young MSM, Project PrEP enrolled a diverse sample of 78 eligible, consenting participants (ages 15-17) at high risk for acquiring HIV and provided them with daily tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) as PrEP for 48 weeks. All study participants tested HIV-negative at the start of the study, and received individualized counseling about HIV risk. During the 48 weeks of PrEP use, adherence decreased at each follow-up period, 23 sexually transmitted infections were diagnosed in 12 participants, and three young males became infected with HIV, although blood samples insinuate they were taking less than two PrEP doses each week.7
The results of this groundbreaking behavioral invention provide evidence that PrEP is both safe and tolerable for adolescents younger than 18 years of age, with few adverse effects, and no increase in sexually risky behaviors during the study period. An editorial accompanying this study argues that the findings also reveal youth may need more support from a multiteam, interdisciplinary, community-oriented approach to address the social and structural barriers that affect their access to PrEP, adherence levels, and interpretation of HIV risk.8
How to Overcome Barriers?
Barriers to HIV PrEP access and prevention include: stigma around HIV and sexual identity, homophobia/transphobia, minority stress, as well as provider discomfort and lack of knowledge about PrEP. Additionally, the previous U.S. history of medical abuse and forced sterilization among people of color contributes to a justified distrust of healthcare and social service systems.9 Access to PrEP is not just a public health issue, but equally important, an equity and justice issue.
Reproductive justice, a term coined by women of color, includes AYA’s equitable access to HIV prevention and care, free from discrimination and violence, to live healthy, productive lives with dignity.10 The Society for Adolescent Health and Medicine position paper on the use of medication by AYA further emphasizes that medication regimens should center on the experiences of youth and be “built around the life context of the AYA.” The society recommends a nonjudgmental and empowering approach to increase adherence of medications, and underscores the importance of access to medications easily, confidentially, at low or no cost, and free from stigma.11
Youth-serving health professionals can work toward ensuring equit-able access to HIV PrEP for all adolescents. Use the following resources to expand training and education:
- Primary Care Development Corporation (PCDC) High Impact Prevention (HIP): www.pcdc.org/hip;
- University of California San Francisco Clinician Consultation Center, National Rapid Response for HIV Management and Bloodborne Pathogen Exposures: http://nccc.ucsf.edu.
By reducing HIV-related disparities, and increasing individual choice around sex, sexuality, and HIV prevention, clinicians can work toward ensuring reproductive justice.12
REFERENCES
- Centers for Disease Control and Prevention. HIV Among Youth. Fact sheet. Available at: http://bit.ly/2kbvQN3. Accessed Oct. 16, 2017.
- Koblin BA, Mayer KH, Eshleman SH, et al; HPTN 061 Protocol Team. Correlates of HIV acquisition in a cohort of black men who have sex with men in the United States: HIV Prevention Trials Network (HPTN) 061. PLoS One 2013; 8:e70413.
- Centers for Disease Control and Prevention. HIV Surveillance Report: Diagnoses of HIV Infection in the United States and Dependent Areas, 2015. Available at: http://bit.ly/2gTB1iZ. Accessed Oct. 16, 2017.
- The White House. Office of the Press Secretary. The National HIV/AIDS Strategy: Updated to 2020. Fact sheet: Available at: http://bit.ly/2xE2JJa. Accessed Oct. 16, 2017.
- Anderson PL, Glidden DV, Liu A, et al; iPrEx Study Team. Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Sci Transl Med 2012;4:151ra125.
- Fonner VA, Dalglish SL, Kennedy CE, et al. Effectiveness and safety of oral HIV preexposure prophylaxis for all populations. AIDS 2016;30:1973-1983.
- Hosek SG, Landovitz RJ, Kapogiannis B, et al. Safety and feasibility of antiretroviral preexposure prophylaxis for adolescent men who have sex with men aged 15 to 17 years in the United States [published online Sept. 5, 2017]. JAMA Pediatr. doi:10.1001/jamapediatrics.2017.2007
- Arrington-Sanders R. Human immunodeficiency virus preexposure prophylaxis for adolescent men: How do we ensure health equity for at-risk young men? JAMA Pediatrics 2017; doi:10.1001/jamapediatrics.2017.2397.
- Auerbach JD, Kinsky S, Brown G, Charles V. Knowledge, attitudes, and likelihood of pre-exposure prophylaxis (PrEP) use among US women at risk of acquiring HIV. AIDS Patient Care STDs 2015;29:102-110.
- SisterSong Women of Color Reproductive Justice Collective. Reproductive Justice. Available at: http://bit.ly/2xFEnyC.
- Society for Adolescent Health and Medicine. The use of medication by adolescents and young adults. J Adolesc Health 2017;61:396-399.
- Gandhi A, Dorsainvil M. Pre-exposure prophylaxis (PrEP) for HIV prevention as reproductive justice issue: Increasing awareness and access among women of color. Presented at the SisterSong Let’s Talk about Sex Conference. New Orleans; October 2017.
Access to HIV pre-exposure prophylaxis is not just a public health issue, but equally important, an equity and justice issue.
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