Response to “Expanding Pre-Exposure Prophylaxis (PrEP) Utilization in the Philippine HIV Crisis”

Thank you for the excellent recent letter to the editor that expands on our study of pre-exposure prophylaxis (PrEP) for HIV prevention in rural and suburban primary care settings ¹ and looks through an international lens at the needs of those at risk for HIV in nonurban settings in the Philippines. Clearly there is a need for research into public health strategies to address HIV transmission in rural areas to reach the goal of HIV eradication globally. While there are a number of studies demonstrating disparities in HIV testing and awareness in rural areas,^2,3 less is known about effective strategies for reducing HIV transmission in these settings.

Likely, strategies to reduce HIV transmission in nonurban settings will need to both target provision of PrEP by rural providers and address the unique structural barriers that patients face in accessing PrEP services. To address provider needs, likely educational programs are not alone sufficient, and telemedicine services or linking networks of experienced providers to provide guidance and mentorship in areas with lower HIV prevalence may be needed. This could be coupled with protocols, order sets or other systems-based solutions that allow for busy providers involved in a wide breadth of clinical care in nonurban settings to provide simple, consistent, high quality HIV prevention services.

From a patient perspective, studies have identified barriers to accessing PrEP services, that are, not surprisingly, dependent on the distance patients must travel to a PrEP provider.^3,4 In the United States (US), this is most apparent in the southeastern US where rural areas account for a disproportionate number of new and later stage HIV diagnoses. ⁵ In rural settings, often the lack of HIV prevention services can be compounded by poor health care infrastructure, which includes primary care. ⁶ Considering the lack of primary care providers and HIV specific treatment centers in nonurban settings, PrEP services may need to be superimposed on existing partnerships or infrastructure that already exists in rural settings, such as drug treatment programs, pharmacies, sexually transmitted infection (STI) clinics, public health services, or other existing governmental services.

While initial education of providers and patients for PrEP services has focused on urban centers with high rates of HIV transmission, it is time to find more effective, practical methods for HIV prevention in nonurban settings in the US, the Philippines, and globally. This research has the potential to reduce existing health disparities and eliminate HIV.