While preexposure prophylaxis, or PrEP, is a vetted, tried and true form of HIV prevention, messaging around the medication — which reduces the riskTrusted Source of contracting HIV from sex by roughly 99% and from injection drug use by 74% — is often directed toward members of the LGBTQ community.
Public health campaigns and ads seen on TV and online often target groups that historically have been at high risk for HIV, namely gay, bisexual, and other men who have sex with men, as well as trans and nonbinary people.
While this has been necessary, important public health work, outreach and awareness have been less visible when it comes to cisgender, heterosexual people. Though, there certainly is a need.
The Centers for Disease Control and Prevention (CDC) reportsTrusted Source that in 2020, people who reported having heterosexual contact accounted for 22% of the 30,635 new HIV diagnoses that year. Within that number, men who reported heterosexual contact made up 7% of new diagnoses, while women who reported heterosexual contact stood at 15% of HIV diagnoses.
Similarly, in the United Kingdom, in the year leading up to December 2021, new HIV cases were higher in heterosexual people than in gay or bisexual men for the first time since the start of the HIV pandemic in that country, according to The Independent.
Experts say, what this all means is more work needs to be done with preventive measures like PrEP overall.
There is still a great need to reach members of the greater queer community, especially LGBTQ people of color and people of lower socioeconomic levels who might be disenfranchised from access to tools like PrEP in the United States and elsewhere.
However, there is also a need to reach other groups that might be at risk and who might not be centering HIV among their potential health concerns.
Inaccurate perceptions that HIV is a ‘gay disease’ continue to flourish
When asked if there is a stigma attached to HIV that might deter cisgender, heterosexual people from even seeking out PrEP in the first place, Dr. Monica Gandhi, MPH, Professor of Medicine and Associate Division Chief (Clinical Operations/ Education) of the Division of HIV, Infectious Diseases, and Global Medicine at UCSF/ San Francisco General Hospital, said a decided “yes.”
“I believe there is stigma attached to PrEP that unfortunately keeps straight/cisgender people from accessing it at the rates this population should. For instance, the CDC estimates that 1.2 million people require pre-exposure prophylaxis in the US, but fewer than 25% are taking it,” Gandhi told Healthline. “Although some of this gap is due to access to PrEP or a lack of awareness of PrEP, stigma likely plays a role in straight, cisgender women, for instance, in not uptaking PrEP where these groups may think this is only a pill or preventive agent for LGBTQ communities.”
David Stein is the CEO and co-founder of at-home diagnostics and testing company Ash Wellness, which offers a range of tests through its platform, including HIV and other STI testing, among other services.
Through his company, he has helped more than 7,500 people get on PrEP in New York through Ash Wellness’s at-home testing services, while the company has collaborated with various partners like community organizations and public health departments to provide PrEP to people across all 50 states.
He echoed Gandhi in saying the stigma that HIV is only something that affects gay and queer people and, as a result, PrEP is a medication just for those groups is embedded in our society.
He said even the way the healthcare system codes and bills for HIV and other STI testing services relates to questions like “have you had sex with a man” or “have you had sex with someone from the continent of Africa,” which are particularly charged, problematic ways to assess who might need HIV testing.
“There are so many stigma points related to that even from the get-go, and you aren’t even talking about PrEP yet. So, yes, I think as a result, people that may not identify with those two questions or may feel the stigma related to that for whatever reason might not even get to the point of ‘ok, you’re a candidate for PrEP,’ ” Stein told Healthline.
Pushing back against stigma
Gandhi said those recent CDC statistics that show 22% of new infections are among heterosexual people in the U.S. “means we have to redouble our efforts to reach heterosexual, cisgender women and men with our PrEP messaging.”
“This should be on people’s radar,” she told Healthline. “In fact, two of the biggest PrEP trials that led to the approval of PrEP were in heterosexual couples, one called Partners PrEP and the other called Botswana TDF. PrEP works well in these populations.”
When asked how to go about combatting stigma that might result in heterosexual people turning a blind eye to HIV risk, Stein said better marketing and advertising needs to be crafted to reach some of these populations.
He added that some hope rests in the form of “Gen Z and newer generations” who seem to have generally more open-minded views of gender and sexuality “outside of binaries of homosexual and heterosexual or male and female.”
Some of these younger generations might be more open-minded to marketing about this medication in a way that older ones might not be.
As an HIV clinician for over 20 years, Gandhi has a unique vantage point of this issue. She said she often treats cisgender women due to her own interest in HIV and women.
“I always offer the male partners of my heterosexual, cisgender women patients PrEP, and the partners often agree. I also receive queries and suggest PrEP for women and men who are heterosexual,” she added.
Clinicians need to be better educated about HIV
Another big issue related to this issue of PrEP education and awareness is some of the stigma perpetuated by clinicians themselves who might not be well-versed in PrEP as a preventive tool for people outside of the LGBTQ community.
“I think clinicians have a poor education when it comes to PrEP as well. I’ve spoken to clients who service middle America, and the reason they do so well there is because many clinicians in some of those states have reported to not even know what PrEP is,” he added.
Stein said that one bright spot in raising general awareness about the medication is the work currently being done by the Biden administration.
“When Biden first got into office, he mandated public and private insurers across the board to cover PrEP … and with this new 2023 budget, it’s historically high funding that he’s proposing for HIV prevention along with a proposed ‘huge budget’ for PrEP coverage for those who are uninsured and underinsured. I’ve been incredibly impressed with that,” he said.
Additionally, he added that the rise of telehealth and “tele-PrEP services” have generally made it more accessible. If you are in a community that might not have a clinician who is well-versed in HIV prevention, some of these services have made it easier to seek that information and receive the PrEP you need.
When it comes to his own company, Stein said Ash Wellness’s goal is to “make at-home testing as inclusive and accessible as possible.” This includes education along with providing testing and medication.
“It’s about saying A, this is something that is important, B, this is not just something affecting homosexual people, and C, it’s also an epidemic in the U.S. right now, just looking at the STI reports every single year, the numbers go up in almost every type of population, every type of geography,” Stein added.
The dangers of not knowing your status
Stein said that society and health messaging as a whole often give cisgender, heterosexual people a false sense that HIV is an issue that can’t possibly affect them. Because of this, there are some people who may never seek testing and might not know their status. It might be the last thing on their mind when comes to their health.
About 15% (about 1 in 7) of people who are living with HIV are not aware of that important fact. This amounts to about 165,000 people nationwide., according to the U.S. Department of Health and Human Services.
“That’s something that is a little bit scary. It is a huge problem,” Stein said. “Also, I would say, speaking to clinicians on the hospital level as we try to sell into these different hospital systems, we speak to ER docs who are seeing patients and someone comes in with unexplained illness, and one of the first things they do is test for HIV. That should tell you everything.”
As with many aspects of daily life, the COVID-19 pandemic also played a role. Like many other routine, preventive health measures, HIV and general STI testing were put on the back burner by some people at the height of the global health crisis.
Some people who might have been at risk for HIV, might have put testing off. For some of the reluctant heterosexual people who didn’t think of this as an issue, the years of the pandemic might have put that further out of their minds.
Stein said one thing that is crucial is that you get tested and that the healthcare system and our society as a whole need to do a better job of eliminating some of this inherent stigma surrounding HIV and STI screenings. It should be seen as a crucial and routine part of healthcare for all people.
Why PrEP is ‘terribly important’
Stein said that he “would be lying” if he said PrEP is “super accessible.”
“I think for white cisgender gay men it is — and that is the majority of the population right now who is on PrEP — but, again, look at the data,” Stein said.
He pointed to the high rates of HIV among Black and Latino men who have sex with men in this country. Data published in 2016 from the CDCTrusted Source showed that about 1 in 2 Black men who have sex with men and 1 in 4 Latino men who have sex with men in the country “will be diagnosed with HIV during their lifetime” if current HIV rates continue.
“So, it’s clearly not accessible enough,” Stein added. “I think, again, it comes back to education — clinicians don’t know about it, and as a result, patients don’t know about it.”
From some of the most vulnerable members of the LGBTQ community in our society to heterosexual people who are conditioned not to see HIV as a concern they should have, both Stein and Gandhi reiterate how important PrEP is.
“We saw this during COVID-19, but behavioral interventions to curb new HIV infections — e.g. condoms — are hard to make work in the real world,” Gandhi added. “Biomedical interventions are the ‘pot of gold at the end of the rainbow’ for preventing HIV, and PrEP is our most powerful strategy, along with treating those living with HIV. It is terribly important that as many people, and providers, know about PrEP as possible.”
