Psychiatrists Have Important Role in Preventing HIV Just by Writing an Rx
The U.S. National HIV/AIDS Strategy is calling on mental health and substance use care clinicians to do something about it.
Individuals with serious mental illness are at increased risk of contracting HIV, and psychiatrists have an important role to play in helping to end this epidemic, according to a speaker at APA’s Mental Health Services Conference in September.
“This really is a remarkable thing we’ve been able to do in our lifetime…. HIV has gone from a death sentence to a preventable chronic illness,” said Samuel R. Bunting, M.D., M.S., a psychiatry resident at the University of Chicago, who also spoke to Psychiatric News. “So, we really need to do a much better job of making evidence-based HIV preventatives available to all patients who could benefit from them.”
“Our patients struggle obtaining care from other parts of the health care system. PrEP is a harm-reduction tool we can easily offer to our patients, and one with enormous individual and population health benefits,” said Samuel R. Bunting, M.D.
Linda M. Richmond
Individuals with psychiatric illness are up to 10 times more likely to contract HIV than those without; risk is even greater among individuals with comorbid substance use disorder (SUD). Moreover, data suggests that about 60% of new HIV diagnoses are in individuals 13 to 34 years old, “which also perfectly coincides with when most severe mental illnesses have their onset,” Bunting said.
Preventive measures are readily available. First approved by the Food and Drug Administration (FDA) in 2012, oral pre-exposure prophylaxis (PrEP) prevents 99% of sexual transmission of HIV when taken daily, as does the eight-week injectable (LAI) option that was approved in 2021. Patients who take oral PrEP at least four times a week still cut their risk of sexual transmission of HIV by 96%. (Among intravenous drug users who take oral PrEP as prescribed, risk is lowered by 74%).
Patients at Risk
The annual number of PrEP users in the United States has risen from just over 10,000 in 2013 to nearly 506,000 in 2023. Despite these gains, only 36% of those who could benefit are taking PrEP, according to the most recent CDC data.
The broad numbers obscure a stark racial inequity: 94% of White people who could benefit from PrEP are receiving the medication, compared with just 13% and 24% of Latino/Hispanic and Black Americans, respectively. To help combat this, the U.S. National HIV/AIDS Strategy has called for the integration of HIV screening and prevention into existing care programs, including those for mental health and substance use disorders.
“I think psychiatrists have a unique role to play, given our relationship and the relatively frequent contact we have with our patients,” Bunting said. “Our patients struggle obtaining care from other parts of the health care system. [PrEP] is a harm-reduction tool we can easily offer to our patients, and one with enormous individual and population health benefits.”
Bunting pointed out that oral PrEP has no REMS, no prior authorization, no prescriber registration requirements, and no DEA waiver to contend with before prescribing. “Anyone with prescribing authority in their state can provide this medication to their patients,” he said. PrEP also does not require much additional work on the clinician’s part. “We’re already doing the labwork and a lot of the evaluations required for PrEP management as a part of routine psychiatric care.”
Yet a recent survey of psychiatrists by Bunting and colleagues found that just 17% have prescribed PrEP. The most often-cited obstacle is limited knowledge of the medications, according to the report issued in Psychiatric Research and Clinical Practice.
Bunting acknowledges that initiating PrEP is not a standard part of medical school or psychiatric residency training. “My training was on the job and involved collaborating with infectious disease physicians and primary care doctors.” He added that it is important to identify colleagues in these fields who can consult on complex cases and help should questions about PrEP management arise.
New Cases Every Year
There are 1.2 million people living with HIV in the United States. What’s more, there were another 31,800 new HIV diagnoses in 2022—a decline of only 12% since 2018, when the U.S. Department of Health and Human Services vowed to slash that number by 90% within 10 years.
About 67% of new cases of HIV in 2022 involved men who have sex with men, while 22% arose from heterosexual contact. About 7% involved injected drug use, whereas 3% involved men who have sex with men and inject drugs. Perhaps not surprising given inequities in PrEP accessibility, 70% of new HIV cases were among Black/African and Hispanic/Latino Americans.
In accordance with CDC guidance, Bunting specifies that psychiatrists should inform all sexually active adolescents and adults about the availability of PrEP for the prevention of HIV. Specifically, the medication is indicated for any person meeting at least one of the following criteria:
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Unprotected sex with one or more sexual partners with an unknown HIV status in the past six months
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Unprotected sex with a sexual partner who is HIV-positive
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Diagnosed with any sexually transmitted infection (STI) in the past six months
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Injecting drugs with shared equipment in the past six months
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Anyone who requests PrEP
The first step is taking a complete sexual history to identify PrEP eligibility, Bunting said. Baseline lab work and STI testing are also required and should be repeated every 90 days as long as PrEP is prescribed. The tests can easily be added to orders for other bloodwork, such as checking lithium or valproate levels, he said.
After the U.S. Preventive Services Task Force gave a “grade A” evidence rating to PrEP, the federal government began requiring insurers to cover generic PrEP and ancillary services, such as lab work, without cost sharing for patients. When it comes to prescribing PrEP, there are multiple FDA-approved products:
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Daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC), generic available; approved for all patients ages 13 and up.
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Daily oral tenofovir alafenamide/emtricitabine (TAF/FTC, Descovy); has fewer side effects than TDF/FTC. Approved only for adults and adolescents at least 35 kg assigned male at birth who have sex with males.
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Intramuscular long-acting injectable (LAI) cabotegravir, approved for all adults and adolescents weighing at least 35 kg. (Apretude, administered every eight weeks after two loading doses four weeks apart).
On the horizon, long-acting subcutaneous lenacapavir (given every six months) has not yet received FDA approval, but the product was shown to be highly effective in preventing HIV in clinical trials in 2024.
Coverage for the LAI version of PrEP typically involves prior authorization because there is a generic oral PrEP option available. “The prior authorization process for the long-acting injectable form can be difficult,” Bunting said. Still, he does not hesitate to go to bat with insurance plans for a patient who has difficulty adhering to oral regimens or who says they prefer injections for privacy reasons.
“Preventing HIV is something that’s within the scope of psychiatric care,” Bunting said. “[A new psychiatric diagnosis] is a period of heightened vulnerability, and if we have folks engaged in our systems of care, prescribing PrEP allows us to provide preventive harm reduction, in addition to treating psychiatric symptomatology.” ■
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Published online: 22 November 2024
Published in print: 22 November 2024
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