The case for prescribing PrEP in community mental health settings

pillIn a recent Lancet article, Christina Mangurian, MD, and colleagues discuss barriers and plausible solutions to community mental health clinics prescribing Pre-exposure prophylaxis (PrEP), a biomedical HIV prevention modality that is up to 99% effective in preventing HIV acquisition through sex if taken as directed. 

PrEP was approved by the US Food and Drug Administration in 2012, and is recommended for use by populations at high risk for contracting HIV, however current estimates are only 20% of those in the USA who have an indication for PrEP also have a prescription for it.  Government efforts encourage partnerships among government agencies to increase knowledge of PrEP among providers.  

While primary care providers and HIV-providers have been engaged in these conversations, perspectives of mental health professionals in community mental health settings are absent from the discussion of prescribing PrEP in the literature. HIV prevention is important to the field of psychiatry considering the high burden of HIV among populations with serious mental illness treated in community mental health settings.  

Successful initiation of PrEP requires that providers counsel patients about HIV risk behaviors and on an individual's ability to take the medication as prescribed. Although data do not currently exist about PrEP adherence among people with serious mental illness, research has shown that individuals with HIV who were in psychiatric care had better adherence to antiretroviral therapy compared with individuals with HIV who were not in psychiatric care. 

Community mental health providers already deliver holistic care that takes into account patients' sexual behaviors and drug use so these settings are therefore ideal to identify PrEP candidates. Providers in these settings take detailed psychosocial histories and are well versed in providing care for substance use disorders, including leveraging harm reduction strategies. In addition, multiple opportunities exist for intervention, given that people with serious mental illness typically access community mental health settings more often than they access primary care settings

The researchers detailed potential barriers including the potential for mental health providers’ attitudes toward PrEP which may share concerns that have been expressed by other providers regarding adherence and risk compensation, as well as the potential that psychiatrists may feel they need more training to prescribe non-psychotropic agents.  With other providers, in response to these concerns, public health detailing—a process by which academic researchers and public health professionals educate providers about PrEP and provide helpful, evidence-based tools to encourage prescribing—has become an important method of improving knowledge of PrEP among providers.

Much like the need for studies evaluating PrEP attitudes and knowledge among mental health providers, research assessing similar constructs among people with serious mental illness is needed. As people with serious mental illness are the key stakeholders in this discussion, their awareness of and interest in PrEP use should be taken into consideration, along with their preferences for PrEP delivery models.

A major structural barrier is whether HIV counselling and preventive services can be reimbursed in specialty mental health settings. If they cannot be reimbursed, these fees might be shifted onto patients with serious mental illness. Additionally, in the USA, the cost of PrEP is variable and can be prohibitive for patients without insurance coverage and who are unaware of industry and federal assistance.

As different models are created to encourage PrEP use in community mental health clinics, high-quality implementation research studies should be done to assess efficacy and effectiveness, and help to clarify the best ways forward. It is important to remember that HIV care and treatment advocacy has led the way in promoting health care as a form of social justice, one in which no individual is neglected.

Christina Mangurian, MD

Dr. Mangurian is affiliated faculty at the Philip R. Lee Institute for Health Policy Studies, a Professor of Clinical Psychiatry at UCSF School of Medicine and the UCSF Department of Psychiatry's Vice Chair for Diversity and Health Equity. Dr. Mangurian founded and directs the UCSF Program of Research on Mental health Integration among Underserved and Minority populations (PReMIUM) which is based at the Center for Vulnerable Populations. She is a community psychiatrist whose NIH-funded research program focuses on improving diabetes screening and HIV care of people with severe mental illness (e.g., schizophrenia, bipolar disorder), particularly among underserved minority populations.

The case for prescribing PrEP in community mental health settings
Sudler A, Cournos F, Arnold E, Koester K, Riano NS, Dilley J, Liu A, Mangurian C.Lancet HIV. 2021 Apr;8(4):e23