Back Back
Simplifying PrEP Initiation
PrEP Initiation Made Easy: 3 Questions to Ask Your Patients

Released: October 17, 2023

Hyman Scott
Hyman Scott, MD, MPH
Activity Information

Activity

Progress
1
Course Completed
Key Takeaways
  • Prescribing PrEP can be easy, just like with many other routinely prescribed medications.
  • Simplifying the discussion about PrEP normalizes and destigmatizes it, which may help improve uptake.

Initiating pre-exposure prophylaxis (PrEP) can be easy if we make the conversation simple and unintimidating for our patients. I approach it the same way I would any other daily medication we prescribe, such as statins to prevent heart disease or contraception for pregnancy prevention. PrEP doesn’t have to be any different from the preventive care that we routinely provide.

My Approach
PrEP should be discussed with anyone who is sexually active per the new CDC guidelines. We can talk about sex with our patients in a way that gives us enough information about their sexual activity to help determine which PrEP options they are able to use.

I start the conversation about PrEP by asking 3 simple questions.

  1. “Have you heard of PrEP?”
  2. “What are the genders of your sexual partners?”
  3. “Are there times you have sex without condoms?”

These series of questions ultimately lead to the question, “Are you interested in PrEP?”

PrEP Options
Whether the patient identifies as a cisgender man, cisgender woman, transgender woman, or transgender man, it may be necessary to inquire about what type of sex they are having, as that will determine if certain PrEP regimens aren’t appropriate for them.

To address this, I ask only 1 more question of my patients assigned female at birth to clarify if they are having receptive vaginal sex, as that is the main differentiator between the recommended PrEP regimens. A simple yes or no makes it clear which PrEP options are available to a patient. If the answer is no, then all 4 PrEP options—daily emtricitabine (FTC)/tenofovir disoproxil fumarate (TDF), daily FTC/tenofovir alafenamide, on-demand FTC/TDF, or injectable cabotegravir—can be prescribed. If the answer is yes, then there are 2 PrEP options to consider: either daily FTC/TDF or injectable cabotegravir. From there, it’s up to the patient to determine which regimen will work best for them.

Avoiding Pitfalls

“High-Risk” Individuals
Prior attempts to increase PrEP uptake have targeted “high-risk” individuals with limited success. I believe that this approach contributes to PrEP stigma and low uptake. By restricting PrEP access, we are doing exactly that—restricting it in ways we do not intend among those who may most benefit.

By asking broad, simple questions to initiate the conversation about PrEP, rather than focusing on risk, we can reduce stigma because we are not assuming what kind of sex someone is having or the number of partners they have. 

Number of Sex Partners
I de-emphasize the number of partners because 1 partner is enough for someone to acquire HIV. If an individual is having anal or vaginal sex and there are times when they are not using condoms, then that is really all you need to know.

In addition, if they have 1 partner and they feel that they need PrEP, they should be able to get it. We shouldn’t withhold it because we assess them as being at low risk for acquiring HIV. Offering PrEP to everyone regardless of their number of sexual partners normalizes it and makes it more accessible to anyone who is interested. 

Network Dynamics
For many Black and Latino/Latina individuals in the United States, HIV risk is largely driven by network dynamics, or the prevalence of HIV and lower levels of viral suppression within their communities. These complexities certainly affect their HIV risk, but emphasizing them in a conversation about PrEP may contribute to HIV and PrEP stigma. Asking simple questions about condom use identifies an individual’s need for PrEP without attributing any of the risk to a patient’s community.

Stay Humble
One last word of advice: While discussing PrEP with your patients, it is crucial to be humble. Although we are discussing PrEP regimens and asking for information from a clinical standpoint, for the patient in front of you, it really is about their choices, values, body, and autonomy. Although it is important to know what type of sex your patient is having and what type of anatomy your patient has, these questions must be asked in nonjudgmental ways with the utmost respect for the information that is being shared with us. 

Your Thoughts?
How do you initiate conversations with your patients about PrEP? Let us know in the comments.