Strategies for APPs in Primary Care: Promoting PrEP Uptake Among Cisgender Women

Strategies for APPs in Primary Care: Promoting PrEP Uptake Among Cisgender Women Posted By:

As a family nurse practitioner and a researcher at the University of Pennsylvania and Thomas Jefferson University in Philadelphia, my research focuses on cisgender women and pre-exposure prophylaxis (PrEP).

My team and I developed an intervention to promote PrEP uptake among cisgender women. By meeting these women in their community, we discussed with them the importance of primary care in their general health and took the opportunity to educate them on PrEP. We found that many of these women did not already know about PrEP, but once they learned about it, they were interested in it, and expressed enthusiasm at the idea of talking to their primary care provider (PCP) about it.

Common Barriers
We know that PrEP uptake among cisgender women is very low. In 2022, only 14.5% of women who could benefit from PrEP were prescribed it, and this is a medication that has been approved by the FDA for more than 10 years. Unfortunately, cisgender women are often not made aware of PrEP and its benefits. To illustrate this point, more than half (53%) of the women in our study did not know PrEP existed, prior to hearing about it from the study team.

What we did find during this work, however, is that many local PCPs—whom these women trusted and were already seeing—did not know much about PrEP themselves. As a result, the women would be referred elsewhere for PrEP, and often, they did not seek that additional care. The women expressed confusion as to why their PCP did not know about and could not provide PrEP.

The Critical Role of Primary Care
From that lesson, my team and I learned how important it is for PCPs to provide PrEP. And with the growing number of advanced practice providers (APPs) being patients’ PCP, it is especially important for these healthcare team members to be educated and able to provide PrEP education to their patients.

One of the first steps a PCP (or APP) can take is to make their female patients aware of PrEP, which should be a discussion point when talking about safe sex strategies. It is up to us, as PCPs, to be informed and then educate our patients.

According to the CDC guidelines for PrEP and the prevention of HIV infection, PCPs should be talking with all sexually active adolescents and adults about PrEP. Our role is not to figure out who would and would not benefit from PrEP, but rather we should be having conversations with all patients who are sexually active about what PrEP is and how it benefits each of them individually. In addition, when discussing the benefits of PrEP and whether it might be an option for your patients, PCPs should practice shared decision-making. This way, patients have a direct role in determining if PrEP is right for them.

A PCP can identify some of the reasons why women in general might want to use PrEP: for example, if a woman doesn’t know the HIV status of her partner and they are not using condoms or if she uses drugs or alcohol before sex, or if she doesn’t know if her partner has other partners. With such guidance from her PCP, conveyed in a nonjudgmental way, the woman can decide if she might benefit from PrEP.

Patient–Provider Discussion Points
Discussions about PrEP in primary care should be part of  overall sexual health discussions. I have heard from women, in particular, who have concerns about potential adverse effects and their ability to remember to take a pill every day. In addition, some were worried about people judging them negatively for receiving PrEP. These are just some of the concerns PCPs can address up front with their patients.

Women may also have specific concerns about pregnancy or breastfeeding. We know that daily oral PrEP is safe during both pregnancy and breastfeeding, but injectable cabotegravir PrEP does not yet have sufficient data to promote its use among those who are pregnant or breastfeeding.

Before initiating PrEP, there are a series of lab tests that need to be done, including making sure patients test negative for HIV infection. Once those labs come back and it looks like a patient would be a good candidate for PrEP, it is important to discuss treatment adherence and the follow-up required with different PrEP options. If patients choose the daily pill, they need to know that truly taking it every day is critical to ensure full protection against HIV, and for those who choose the injectable, they need to know how often to return to the clinic for their injections and what the dosing window is to ensure continued protection.

A Multidisciplinary Approach to Care
Much of this counseling and education can be delegated to other members of the healthcare team, such as a PrEP counselor, nurse, or medical assistant. These individuals can be trained to help with some of this work so that patients’ visits are more efficient for them and their PCP. This information can be given ahead of time, so the PCP can focus much of their time on the more complex decision-making that is within their skillset.

It is possible that some women see their PCP as their sole healthcare provider. If that PCP and team are not talking with them about PrEP, that is a missed opportunity for prevention. The CDC now recommends this education as a component of routine, preventive care.

Because covering all the basic preventive measures that are now recommended can be time consuming, a team-based approach can be helpful. The practice can have videos playing in the waiting room or educational brochures sitting on tables for patients to access. Staff should help out with spreading some of the more basic information to women before they talk with their PCP. I think these strategies will make it easier and, of more  importance, doable to address PrEP and other prevention measures within the primary care setting.


Filed under: Infectious Diseases , Women's Health , Preventive Medicine , Public Health , NPs & PAs

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