Plan to Prevent or Reduce Cancer

Integrating HIV Preexposure Prophylaxis (PrEP) Into Routine Preventive Health Care to Avoid Exacerbating Disparities

More than 3 decades since its

emergence in the United States,

HIV continues to spread and dis-

proportionately affect socially mar-

ginalized groups.

Preexposureprophylaxis(PrEP),

a highly effective prevention

strategy federally approved since

2012, could fundamentally alter

the course of the epidemic. How-

ever, PrEP’s potential has not been

fully realized, in part because

health care providers have been

slow to adopt PrEP in clinical

practice and have been selective

in their discussion of PrEP with

patients. This nonstandardized

approach has constrained PrEP

access. PrEP access has not only

been inadequate but also in-

equitable, with several groups in

high need showing lower rates

of uptake than do their socially

privileged counterparts.

Recognizing these early warn-

ing signs that current approaches

to PrEP implementation could ex-

acerbate existing HIV disparities,

we call on health professionals to

integrate PrEP into routine pre-

ventive health care for adult

patients—particularly in primary

care, reproductive health, and be-

havioral health settings. Drawing

on the empirical literature, we

present 4 arguments for why do-

ing so would improve access and

access equity, and we conclude

that the benefits clearly outweigh

thechallenges. (Am JPublic Health.

2017;107:1883–1889.doi:10.2105/

AJPH.2017.304061)

Sarah K. Calabrese, PhD, Douglas S. Krakower, MD, and Kenneth H. Mayer, MD

See also Eaton, p. 1862.

The year 2012 was a landmarkyear in the history of HIV prevention. The US Food and Drug Administration approved the first HIV preexposure pro- phylactic agent for prescription: tenofovir disoproxil fumarate with emtricitabine (Truvada). This daily oral antiretroviral medication is effective in pro- tecting HIV-negative adults from acquiring HIV1 and is indicated for those at risk because of sexual behavior, injection practices, or both.2

Preexposure prophylaxis (PrEP) is an important addition to the menu of prevention options offered to patients in health care settings because traditional pre- vention methods, such as con- doms, have only partially addressed the HIV epidemic. HIV continues to spread, with transmission accelerated among certain groups in particular (e.g., Black men who have sex with men [MSM]3,4). Whether used alone or combined with other prevention methods, PrEP con- fers numerous benefits and few known risks. Many of the ben- efits are unique to PrEP and cannot be obtained via other forms of protection, including its potential for covert use without a partner’s knowledge, allowance of HIV-protected natural conception, dual pro- tection against both sexual and injection risks, and dissociation

from the timing of an exposure event (thus avoiding decision- making in the “heat of the mo- ment” or when judgment is impaired by concurrent sub- stance use).

Despite the immense promise ofPrEPandtheuniqueadvantages it affords, many health care pro- viders, including those aware of this recent prevention innovation, have not discussed PrEP with their patients or prescribed it.5,6 Pro- viders have reported several bar- riers to prescribing PrEP, such as difficulty determining eligibility and time demands associated with provision and follow-up moni- toring,5,7 butpreliminaryevidence suggests that these challenges may be overestimated and are often manageable in practice.8

The slow adoption of PrEP in clinical practiceshascontributedto the gap between the number of people who have taken PrEP in the United States, which is around 100 000,9 and the number at sig- nificant risk for HIV and for whom PrEP is indicated, which exceeds 1.2 million.10 Further- more, the nonstandardized

approaches to PrEP provision in clinical practices that have adopted PrEP may limit PrEP education and access for some individuals more than others,11 thus pro- moting inequities.

We argue that PrEP should be discussed with all adult patients as part of routine preventive health care— particularly in primary care, reproductive health, and be- havioral health settings—and made available to those who elect to use it unless medically contraindicated. Providing all patients with a basic over- view of PrEP ensures that all are aware of its existence, and further education and provision can be tailored to patients’ individual preferences and circumstances. Routinizing the discussion and offering of PrEP would improve access to PrEP, thereby curbing HIV spread, and improve access equity for Black MSM and other socially marginalized groups disproportionately affected by HIV, which would help avoid exacerbat- ing existing HIV disparities through PrEP-related clinical practices.

ABOUT THE AUTHORS Sarah K. Calabrese is with the Department of Psychology, George Washington University, Washington, DC. Douglas S. Krakower and Kenneth H. Mayer are with the Fenway Institute, Boston, MA, and the Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston.

Correspondence should be sent to Sarah K. Calabrese, 2125 G Street NW, Washington, DC 20052 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

This article was accepted August 3, 2017. doi: 10.2105/AJPH.2017.304061

December 2017, Vol 107, No. 12 AJPH Calabrese et al. Peer Reviewed Perspectives From the Social Sciences 1883

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CONTEXT AND DEFINITION

According to the 2015 US national HIV/AIDS strategy,

All Americans deserve scientif- ically accurate, easy-to-access information about HIV trans- mission and prevention. This entails providing clear, specific, consistent, and scientifically up-to-date messages about risk and prevention strategies.12(p4)

Educating the US public about PrEP and other HIV prevention options is a shared responsibility among govern- ment, schools, media, and other entities. However, health care providers can play a particularly pivotal role in disseminating this information because of their medical training and capacity to immediately link individuals to prevention resources and perform associated medical monitoring.

Presently, health care pro- viders’ knowledge of PrEP and adoption of PrEP in clinical practice may be perceived as optional and discretionary. This needs to be revised in the face of strong cumulative evidence for PrEP’s effectiveness across di- verse populations, including MSM, heterosexual men and women, and people who inject drugs.1 Neglecting to consis- tently inform patients about PrEP, especially when providing other sexual health services, may be considered suboptimal care. Routine PrEP education and provision would diminish the selection biases and missed op- portunities inherent in the pres- ent nonstandardized approach.

In the health care system, routinization involves the insti- tutionalization of clinical activi- ties to follow an established pattern with the goal of im- proving medical decision- making and overall community

health.13 Addressing sex- and drug-related risk behavior and health needs, including HIV prevention, should be considered a health priority for all patients that cuts across medical disci- plines. People at risk for HIV have reported diverse preferences for sources of PrEP information and care, including primary care physicians, infectious disease specialists, gynecologists, and psychiatrists,14,15 and it is in- cumbent on all health care pro- viders to offer or support access to PrEP resources. Providers, particularly those practicing in primary care, reproductive health, and behavioral health settings, should be prepared to routinely perform nonjudgmen- tal sexual health and substance use assessments and to discuss PrEP as 1 of multiple HIV prevention options available.

To maximize the quality and range of services that providers are able to offer, PrEP should be embedded in a broader, on- going discussion of sexual and behavioral health that also in- corporates sexual history and goals, other sexually transmitted infections, pregnancy, and sub- stance use. Multiple resources are available to support pro- viders in discussing and provid- ing PrEP (e.g., the National LGBT Health Education Center [http://bit.ly/2vlb9UK], the Clinician Consultation Center [http://bit.ly/2gjqj68]), and technology can help minimize the time demands associated with sexual and behavioral health discussions.16

Routinization has been an effective strategy to help nor- malize and promote uptake of other sexual health prevention services. For example, contra- ception, which was heavily stig- matized in its early days, is now more commonly discussed and offered to female patients of

reproductive age regardless of their stated sexual activity and pregnancy risk. In the realm of HIV testing, moving from a client-initiated (often referred to as “voluntary”) testing model, according to which HIV testing is performed by patient request, to a provider-initiated model, according to which testing is regularly offered to patients as part of standard medical care, has been shown to extend the reach of this valuable service.17

Although both contraception and HIV testing still face some implementation difficulties and have not been routinized across all medical settings, the more commonplace provision of these services relative to earlier implementation efforts bodes well for the uptake and normal- ization of PrEP if integrated as a standard option within preven- tive health care.

Instituting a routine ap- proach to PrEP education and provision comes with chal- lenges, and various strategies for motivating and regulating such change will need to be explored. Health care providers and ad- ministrators will have to be educatedaboutPrEPandperceive value in adopting a routinized approachintheirclinical practices. Securing approval and formal endorsement from medical au- thorities and revising clinical guidance to reflect this recom- mendation may help promote buy-in. Enhancing the visibility of health care settings that have successfully adopted a routinized model of PrEP education and provision could demonstrate fea- sibility and help cultivate new norms that encourage similar in- stitutions to follow suit.6 Linking discussion of PrEP to services that are already being routinely provided in a certain setting, such as HIV testing, is a logical pairing that may facilitate

implementation of a routinized approach to PrEP.

Structural initiatives could also be considered as a means of ensuring routine PrEP edu- cation; for example, existing state laws that mandate offering HIV testing to patients could be amended to also require PrEP counseling for those who test negative. Although there are certain to be obstacles to rou- tinizing PrEP in preventive care, the potential public health benefits of a more equitable and effective approach to imple- menting PrEP are substantial, realistic, and worthy of additional investment.

HOW ROUTINIZATION IMPROVES ACCESS AND EQUITY

We draw on the empirical literature to present 4 arguments for integrating PrEP into routine preventive health care, high- lighting the mechanisms by which a routinized approach to PrEP discussion and provi- sion would improve access and avoid exacerbating existing HIV disparities (Table 1 provides a summary). Of note, we have anticipated criticisms of this approach involving concerns about cost-effectiveness, pro- vider time constraints, side effects and safety, and impact on other sexually transmitted infections. Appendix A (available as a sup- plement to the online version of this article at http://www. ajph.org) provides a summary and counterarguments of these anticipated criticisms.

Avoids Missing Potential Candidates

Individuals at risk for HIV are not easily identifiable. HIV risk is unlike many other medical

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conditions or health concerns that providers routinely diagnose on the basis of direct observation of symptoms. Although a minority of patients at risk for HIV have clinical signs of recent condomless sex or injection drug use (e.g., pregnancy, other sexually trans- mitted infections, needle marks) that may cue providers to possible HIV risk, many patients do not. Thus, “diagnosis” of HIV risk relies heavily on secondhand in- formation obtained through patient self-report. Patients may not accurately disclose the extent

to which they are consistently using condoms, clean needles, and other methods of protection and whether they consider these methods to be acceptable for multiple reasons, including dis- comfort with sharing sensitive information and fear of provider judgment. MSM—and Black MSM in particular18—may be uncomfortable disclosing their same-sex sexual behavior to pro- viders because of anticipated or internalized heterosexism (i.e., negative attitudes toward sexual minorities). Additionally,

if patients are unaware that a provider is conditioning PrEP education and access on their disclosure of relevant risk behav- ior, they may lack incentive to disclose such behavior.

Even if patients were fully forthcoming about their sexual histories and goals, providers broaching PrEP only with patients they judge to be at substantial risk for HIV is problematic because risk pre- diction is an imperfect process. The US Public Health Service2

and other health authorities have

published clinical guidelines containing eligibility criteria to help determine HIV risk and PrEP candidacy, but these cri- teria are not sensitive to all pa- tients who stand to benefit from PrEP. Therefore, if providers use these criteria to identify patients with whom to discuss PrEP, some PrEP candidates will be missed. In 1 longitudinal study,19 only 65% of Black MSM who seroconverted would have met US Public Health Service criteria for PrEP at the previous study time point.

TABLE 1—Arguments in Favor of Integrating Preexposure Prophylaxis (PrEP) Into Routine Preventive Health Care

Argument General Premise Main Points

1. A routinized approach avoids

missing potential PrEP

candidates

Providers broaching PrEP with all

patients would ensure that PrEP

information is provided to all who

stand to benefit

Because patient risk behavior is not readily observable, providers may have difficulty assessing

patients’ level of HIV risk

If PrEP is only discussed with patients who providers perceive to be at risk, some at-risk patients will

not be recognized and will not be informed about PrEP even though they could benefit from it

Eligibility criteria put forward by the US Public Health Service and other authorities are not sensitive

enough to identify all patients at risk for HIV

Absent a routinized approach, decisions about whom to discuss PrEP with will be vulnerable to social

biases

Providers failing to discuss PrEP with patients who could benefit from its use is particularly

concerning because many at-risk patients do not know about PrEP and are not learning about it

from other sources

2. A routinized approach helps

destigmatize PrEP

Making discussions about PrEP part

of routine care would normalize

PrEP for patients,providers, and the

general public, thereby improving

access

Presently, many people see PrEP as a medication for gay men or a sign of promiscuity

Present perceptions of PrEP may deter PrEP candidates from seeking PrEP from a provider or

initiating PrEP when recommended by a provider

Present perceptions of PrEP may interfere with providers’ ability to recognize PrEP candidates or

make them reluctant to broach the topic for fear of offending patients

Changing present perceptions of PrEP among members of the general public could increase support

for policies and programs that support access

3. A routinized approach

facilitates patient-centered care

Routinization empowers patients to

help decide whether PrEP is right

for them

Patient-centered care is the preferred approach to service provision in many health professions

Routinization alleviates challenges that providers may experience in determining eligibility

Providers deciding not to broach the topic of PrEP with a patient is a decision made with incomplete

information (e.g., about a patient’s sexual history and intentions)

Patients have unique insight into their past and future level of risk

There is significant benefit and limited risk to discussing PrEP with patients and involving them in

the decision-making process

4. A routinized approach

transmits knowledge about

PrEP to the broader community

Routinely educating patients about

PrEP might help inform and engage

other members of the community

who are in patients’ social networks

PrEP awareness in the United States remains low

Patientswho learnaboutPrEP fromtheirhealthcare providers can sharethis informationwithother

people in their social networks

Routine PrEP education provides an opportunity for providers to help disseminate accurate

information about PrEP and correct misconceptions in the community

Increased PrEP education and uptake within a social network may reduce medical mistrust and

increase receptivity to PrEP among individuals who do not usually seek medical services

Note. Anticipated criticisms and counterarguments can be accessed in Appendix A (available as a supplement to the online version of this article at http://www. ajph.org).

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Notably, 88% of White MSM who seroconverted in this same study would have met criteria.19

Cross-sectional survey research has revealed a similar disparity, reporting sexually active Black MSM to be less likely than their White and Hispanic counter- parts to meet PrEP eligibility criteria.20 These data raise con- cern that current clinical criteria may not only miss PrEP candi- dates, but miss Black PrEP candidates in particular.

Racial disparities in PrEP eligibility according to preestab- lished criteria may reflect the failure of such criteria to suffi- ciently capture the social and structural risk factors driving the HIV epidemic in the Black community and driving HIV disparities19,20; for example, because people tend to choose sexual partners of the same race and the HIV prevalence among Black MSM is dispro- portionately high,3 each con- domless sex act with a partner from this partner pool carries higher risk on average.

This network-level risk factor is not accounted for in standard PrEP eligibility criteria. (The US Public Health Service guidelines2 do encourage clini- cians to consider epidemiological context, but this recommenda- tion is not consistently captured in the listed indications for PrEP use commonly referenced as eligibility criteria.) Thus, providers should not rely on preestablished eligibility criteria to determine who should be educated about PrEP, as this could inappropriately disqualify Black MSM and others, ampli- fying existing HIV disparities. Rather, preestablished criteria should be regarded as useful but not exclusive cues that PrEP might be appropriate. Likewise, when making specific recom- mendations about PrEP, it is

critical that providers consider factors beyond individual-level criteria, including local HIV epidemiology, HIV prevalence within patients’ sexual networks (if known), and patients’ perceptions of their likelihood of benefiting from PrEP, to avoid inadvertently discouraging PrEP use among patients at risk.

In the absence of a routinized approach to PrEP education, whereby all adult patients receive at least basic information about PrEP, a provider’s decision about whether to inform a patient about PrEP is likely to be gov- erned by both perception of the patient’s HIV risk and the projected impact of PrEP on the patient’s health. Assessment of this impact may include judgments about the patient’s likelihood of adhering to a PrEP regimen and the likelihood of using other risk reduction strat- egies (e.g., condoms) concomi- tantly as encouraged in PrEP clinical guidance.2 Previous sur- vey research with medical stu- dents suggests that clinical decision-making related to PrEP —including assumptions about patient behavior while taking PrEP and consequent intention to prescribe PrEP to a patient— may be vulnerable to biases re- lated to patient race and sexual orientation.11,21 For example, when presented with a clinical vignette about a hypothetical MSM patient seeking a pre- scription for PrEP, medical stu- dents judged the patient as being more likely to increase con- domless sex if prescribed PrEP when they were told he was Black as opposed to White; an- ticipated increase in condomless sex was associated with lower intention to prescribe PrEP to the hypothetical patient.11

Such social biases are especially problematic because of the current epidemiology of HIV,

according to which Blacks, MSM, and Black MSM specifi- cally are disproportionately af- fected.3 Failure to routinely educate and offer PrEP to patients allows providers’ personal biases— whether conscious or not—to govern patient information and access to PrEP.

Finally, it is worth noting that providers neglecting to raise the topic of PrEP with at-risk patients is of particular concern because many such individuals are still unaware of PrEP22 and are hence dependent on their pro- viders to introduce the topic. In some communities,awarenessmay be especially limited among racial and ethnic minority groups in which HIV incidence is dispro- portionately high.22 Furthermore, even among PrEP-informed in- dividuals, reliance on patient agency over provider initiative inbroachingthetopicofPrEPmay disadvantage some groups: recent research with MSM in New York City found that Black and Latino MSM were more likely than were other MSM to prefer that their health care provider lead health care decision-making, and that Black and Latino MSM perceived greater challenge in talking about sex with their provider in the processofobtainingPrEP.23 Other preventive health tools, including seatbelts, bicycle helmets, and condoms,areusuallylearnedabout from 1 or more other sources, such as parents, peers, schools, and media. They are also reinforced by other mechanisms (e.g., state laws, peer norms, situational reminders). That these alternative sources of education and re- inforcement are largely lacking for PrEP makes it all the more im- portant that this prevention tool be routinely discussed in health care settings to ensure that potential PrEP candidates are not missed.

Helps Destigmatize Preexposure Prophylaxis

According to the World Health Organization’s 2016 guidelinesonPrEPimplementation,

Broadening PrEP recommendations beyond narrowly defined groups (such as MSM and serodiscordant couples) allows more equitable access, [and] is likely to be less stigmatizing than targeting specific risk groups.24(p56)

Routinization of PrEP edu- cation and provision in pre- ventive care would facilitate PrEP access by helping nor- malize its use, fostering greater acceptance among potential candidates, providers, and the broader public.

Presently, PrEP is perceived by many as a medication specific to gay men and an indicator of promiscuity.25–28 Both associa- tions may discourage PrEP can- didates from seeking PrEP, as they may fear being judged or “outed” by providers, peers, and others or wrongly assume that they are in- eligible.14,27,28 Such assumptions may also dissuade them from initiating PrEP when recom- mended by a provider. Research, publichealth,andmedia discourse on PrEP has largely focused on PrEP for MSM because of this population’s disproportionate risk for HIV relative to other social groups. An inadvertent conse- quence of this focus has been cultivation of the perception that PrEP is a medication specific to MSM, which may operate as a deterrent to PrEP use for peo- ple at risk for HIV who are not MSM (e.g., women14,29) and to MSM who wish to maintain privacy about their same-sex sexual orientation.25,27

Early research suggests that Black and Latino MSM perceive greater stigma about PrEP than do their White counterparts in some communities30 and have

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greater concern about people noticing and making assumptions about their PrEP use than do other MSM.23 Thus, the destig- matization of PrEP is particularly essential for encouraging PrEP access among racial and ethnic minority MSM. Integrating PrEP into routine preventive care by discussing it with all patients and providing it to those who elect to use it would help reframe it as medication appropriate for sexually active individuals irre- spective of sexual orientation or partner sex, consistent with its indication.

PrEP stigma affects demand by potential candidates and supply by health care providers. With the current nonroutinized approach, providers who are familiar with stereotypes of PrEP users as gay, exceptionally risky, or both may fail to recognize PrEP candidates who do not fit these preconcep- tions on the basis of their gender or self-presentation. At the same time, providers may be reluctant to broach the topic of PrEP with patients belonging to stereotyped groups for fear of offending them by insinuating stereotypical assumptions.

In addition to removing PrEP stigma as a barrier to both patients’ seeking and providers’ prescribing PrEP, routinizing conversations about PrEP would help destig- matize it in the eyes of the general public. This may influence public support for policies and programs that make PrEP affordable for many patients and improve access for racial and sexual minorities in particular.31

Facilitates Patient- Centered Care

A patient-centered model of care aligns with the values put forward by the Institute of Medi- cine,32 the American Medical Association,33 and other

professional organizations dic- tating medical codes of conduct. Providers should present PrEP as a preventive option and sup- port patients in making an in- formed decision about whether it fits with their sexual experi- ences and goals.

Routinely discussing PrEP with patients could help alleviate thepressureordiscomfortproviders experience when deciding PrEP eligibility by making it a shared endeavor with their patients. Some providershaveanticipateddifficulty identifying PrEP candidates to be a potential barrier to PrEP pro- vision,inpartbecausetheyperceive many providers to lack the skills needed to effectively communicate about sexual health with patients.7

With discussion of PrEP left to provider discretion, this difficulty could serve as a barrier to even broaching the topic. Providers may feel less intimidated by the prospect of determining a patient’s PrEP eligibility if they routinely engage patients in shared decisions about PrEP, similar to contraception decision-making, as opposed to having to decide alone whether to initiate a conversation about PrEP. Patients possess significantly greater insight into their sexual histories and intentions than do their providers, even when they are fully forthcoming in sexual health discussions. Thus, patients can offer complementary expertise to providers’ medical knowledge when approaching PrEP decision– making. Failing to broach the topic with a patient constitutes one- sided decision-making on the basis of incomplete data.

If educating patients about PrEP was routinized, providers may be motivated to seek skills-based training on discus- sing sex with patients and could build competence and confi- dence in this area by way of experience. Recent survey re- search suggests that 1 in 4

primary care providers are not comfortable discussing sexual activities with their patients5

and that clinicians tend to overestimate patients’ sensitiv- ity to questions about sexual orientation.34 Resources are readily available to support providers in communicating about sex with their patients and cultivating a safe environment for patients of diverse back- grounds to disclose personal information (e.g., the CDC sexual history-taking guide [https://www.cdc.gov/std/ treatment/sexualhistory.pdf] and the Do Ask, Do Tell toolkit [http://doaskdotell.org]). Rou- tinizing conversations about PrEP could foster an ongoing open dialogue about sex- ual health, building patient– provider rapport over time and enhancing patients’ comfort discussing potentially stigmatiz- ing behavior. This could allow providers to make more in- formed recommendations about PrEP to patients, help them better address other dimensions of sexual health such as re- lationship safety and sexual satisfaction, and serve as a gate- way to patients accessing other health services.

There is minimal harm in broaching the topic of PrEP with all patients, including those not currently at substan- tial risk for HIV. Patients are unlikely to initiate PrEP if they perceive no benefit in doing so. A patient who expresses a de- sire for PrEP is likely to be mo- tivated by perceived HIV risk, irrespective of whether associ- ated behavior has been disclosed. Evidence for greater PrEP interest or willingness among MSM who perceive HIV risk, engage in risk behavior, and report a previous sexually transmitted infection20,35

suggests a correlation between the decision to use PrEP and need

for PrEP. PrEP-seeking patients who perceive themselves to be at risk for HIV despite minimal risk taking, sometimes pejoratively labeled the “worried well,” are uncommon; however, even these individuals may de- rive benefit from PrEP (e.g., reduced anxiety).36 Discussing PrEP and other aspects of sexual health with patients at low perceived risk or who ulti- mately decline PrEP is not a wasted effort, as an in- dividual’s sexual risk taking often fluctuates over time and PrEP may be a desirable option in the future. Additionally, patients’ readiness to initiate PrEP may evolve over time,37

so it is preferable to introduce PrEP as early as possible re- gardless of likely uptake at first introduction.

Transmits Knowledge to the Broader Community

Awareness of PrEP has been slow to permeate the US general public, including subgroups at disproportionately high HIV risk. For example, in a study of HIV- uninfected, sexually active Black MSM in Atlanta, Georgia,38

less than a quarter were aware of PrEP, and no significant in- crease in awareness occurred be- tween 2012 (before US Food and Drug Administration ap- proval) and 2014, nearly 2 years after US Food and Drug Ad- ministration approval. Women at high risk for HIV have expressed anger over not being informed about PrEP sooner14,29

and concern about their health care providers being uninformed about PrEP.14 Low awareness and misconceptions about PrEP, including the notion that it is indicated exclusively for MSM, may be corrected by providers, and this knowledge may in turn help remedy unawareness

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and misinformation in the community.

Medical mistrust has been identified as a potential deterrent to PrEP uptake, particularly among Black MSM.39 Individuals with high levels of medical mis- trust are unlikely to seek medical services and will consequently lack the opportunity to receive education about PrEP directly from a medical provider. How- ever, education of these in- dividuals’ social networks by providers can indirectly raise their awareness about PrEP. Routinization may help erode concerns about the safety and legitimacy of PrEP to the extent that it results in more members of their social networks being informed about PrEP and initi- ating PrEP use, and this may ultimately increase their re- ceptivity to considering PrEP as a prevention option for themselves.

CONCLUSIONS It is an ethical imperative

for health care providers to offer PrEP to those who might benefit and for other health professionals to implement stan- dards and systems that would support the routine discussion and provision of PrEP in health settings. Although some may have reservations about a routin- ized approach, we argue that these concerns are outweighed by the numerous benefits PrEP offers (Appendix A). Presently, PrEP education and provision being optional and selective un- fairly restricts access for many individuals. Moreover, it sys- tematically disadvantages Black MSM and other populations who stand to benefit the most from PrEP and has the poten- tial to widen HIV disparities. Routinization helps circumvent

factors that may limit access for these priority populations, such as provider bias and patient nondisclosure.

Preliminary signs of dispro- portionately low national PrEP uptake among Blacks versus Whites in general,40 and among Black MSM versus White MSM in particular,20 demand imme- diate action to remedy inequities in PrEP education and access. Making PrEP a standard com- ponent of preventive health care for all patients would be a significant step that health professionals could take in this direction. Additionally, pro- fessional organizations and other authorities that establish standards of practice should strongly consider endorsing this approach in clinical guide- lines and training curricula. Setting the expectation that PrEP should be an integral part of routine preventive care could stimulate more frequent discussions about PrEP, more effective use of PrEP, and more equitable access to PrEP, which could decrease HIV incidence and avoid worsening HIV disparities.

CONTRIBUTORS S. K. Calabrese led the conceptualization and writing of this article, with significant input at all stages from D. S. Krakower and K. H. Mayer.

ACKNOWLEDGMENTS This work was supported by the National Institute of Mental Health (NIMH; awards K01-MH103080 and K23-MH098795 to S.K.C. and D.S. K., respectively). Addi- tional support was provided from the District of Columbia Center for AIDS Research (award P30-AI117870) and the Harvard University Center for AIDS Research (award P30-AI060354), both of which are funded by the National Institutes of Health (NIH). D.S. K. and K.H.M. have conducted research with unrestricted project support from Gilead Sciences, and K.H.M. has conducted research with unrestricted project support from Merck and ViiV Healthcare.

K. H. M. is a senior member of the faculty and advisory board of the Na- tional LGBT Health Education Center

and an associate editor and contributor to educational materials provided through the organization’s Web site, to which readers of this article are re- ferred. S. K. C. and D. S. K. have con- tributed to these educational materials as well. All 3 authors have received compensation for their efforts in developing or delivering medical education related to preexposure prophylaxis.

Note. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH or the NIH.

HUMAN PARTICIPANT PROTECTION Institutional review board approval was not needed because this analytic essay does not present an original research study involving human participants.

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