AAP Voices Blog

“We’re excited to be able to offer this new option to patients,” I said and watched the tension and anxiety melt away from the 17-year-old patient before me. This patient had the remarkable courage and maturity to ask his pediatrician what HIV pre-exposure prophylaxis (PrEP) was and then to return for an appointment with a subspecialist. Nonetheless, it was a surprise to him that we would be excited to help him engage in sexual intimacy safely.

This was 2018 and PrEP had only recently been approved for individuals who might weigh less than average adults. As a part of comprehensive sexual health counseling, I was explaining what PrEP was: antiretroviral medications for HIV-uninfected people at high risk for acquiring HIV. I went on, “When taken daily, HIV pre-exposure prophylaxis, or PrEP, is more than 99% effective in preventing infection with HIV.”

Effective, tolerable antiretroviral therapy for people with HIV has revolutionized the pediatric HIV epidemic, dramatically decreasing the number of infants born with HIV each year in the United States. However, some patients seen in pediatric practices are at risk for HIV acquisition or may be in the near future. Sexual-minority males in particular bear a disproportionate burden of the HIV epidemic but have limited access to prevention options in part due to decreased sexual education in schools and stigma from some health care providers.

After the landmark Adolescent Medicine Trials Network for HIV/AIDS Interventions studies 110 and 113 described the safety and feasibility of PrEP in adolescents, PrEP was FDA approved for those weighing 35 kilograms or more in 2018, four years after adult approval. There are two one-pill daily two-drug combination medications available in the U.S.: tenofovir disoproxil fumarate plus emtricitabine and tenofovir alafenamide plus emtricitabine, the latter currently approved only for those assigned male sex at birth. Since PrEP was first approved, we have made enormous strides in increasing the numbers of primary care pediatric, adolescent, and adult providers offering PrEP.

Yet persistent age-based disparities should galvanize us to action: Only a tenth of adolescents and young adults who could benefit from PrEP were prescribed PrEP in 2018. One in five new HIV infections occurs among youth ages 13-24, and 44% of those youth with HIV are unaware they have acquired infection. The CDC estimates that the highest rate of onward transmissions by age arises from youth with HIV.

The first guidelines for HIV pre-exposure prophylaxis focused on individuals at the highest risk of HIV acquisition, however the preview of forthcoming CDC draft guidelines suggests a more expansive approach. Individuals who engage in anal or vaginal sex with inconsistent condom use would all be PrEP-eligible; further, prescribing PrEP to all those who are interested in taking it, even if specific risk behaviors are not reported, is permitted. While the new guidelines are still in draft form, they reflect an increasing recognition that risk changes dramatically in adolescence, and that our ability to ascertain HIV risk – both as patients and providers – has its limitations.

So where are the missed opportunities? HIV PrEP should be part of the conversations we have about sexual health, just as condoms and contraception are. Even if the patient in front of you isn’t sexually active or at risk now, they might be later; for example, the CDC has estimated that a black man who has sex with men has a 41% chance of being diagnosed with HIV over their lifetime. Thanks to increasing public awareness (advertisements during the Olympics were responsible for a few recent referrals to our clinic), more and more patients are asking about PrEP.

There are recent exciting advances to share with these patients -- a substantially less costly generic formulation of tenofovir disoproxil fumarate and emtricitabine recently became available (price $360 annually), and long-acting injectable cabotegravir and a vaginal ring are being considered by the FDA. Several additional delivery modalities, including microbicides, rectal douches and long-acting antibody infusions are being studied. These hold the promise to offer more choices to meet the diverse needs and desires of our patients.

“Unfortunately, many adolescents and youth have never heard about PrEP.”

Unfortunately, many adolescents and youth have never heard about PrEP. A diligent 18-year-old college student whom I met last month, newly diagnosed with HIV, had had sexual health counseling in his pediatrician’s office and sexual education at school, but does not recall anyone who had ever mentioned PrEP. With highly effective prevention options available, each new diagnosis is even more heartbreaking.

Just as many pediatricians pride themselves on keeping up with the latest Disney and Marvel characters to connect with their patients, we can familiarize ourselves with where many patients are receiving their sex education these days, including from the eponymous show on Netflix and the nurse in this 30-second video clip from the series offers a succinct example of PrEP education in action.

If you are thinking about starting to prescribing PrEP, it’s important to note state-specific laws around PrEP provision and consider to what extent you can assure patient confidentiality in your own institution. The CDC, NASTAD and AAP have terrific adolescent-specific resources to help providers interested in prescribing PrEP, but, even if you won’t be prescribing yourself, pediatric and HIV care providers are uniquely poised to share the existence of this exciting option with patients – just as we do with birth control and condoms.