In 2012, the U.S. Food and Drug Administration (FDA) approved the use of the first-ever drug to protect against HIV in high-risk uninfected individuals. Studies showed
that Truvada, when taken consistently, greatly reduced the
risk of infection in men having sex with men and transgender
women having sex with men, prompting one FDA panelist to
say Truvada was “an amazing opportunity to turn the tide on
Two years later, the number of Americans taking the pill
is minute compared to the half-million who the Centers for
Disease Control and Prevention (CDC) thinks could benefit
from Truvada, otherwise known as pre-exposure prophylaxis or
PrEP. Its manufacturer, Gilead Sciences, surveyed 55 percent of
pharmacies in the United States and found they had issued only
2,300 prescriptions for the drug.
Why has adoption been so slow? Some health-care providers
and HIV/AIDS organizations frown upon PrEP. They worry
that lack of adherence could lead to drug resistance, and that
the drug could encourage condom-free sex that spreads other
Patients, meanwhile, may lack access to or even knowledge
of the drug, or have underlying psychosocial conditions that
prevent them from taking it correctly and consistently.
That’s where psychologists come in. They can play an
important role in drug uptake and maintenance, and in helping
at-risk patients determine if PrEP is right for them, according to
David Martin, PhD, senior director of APA’s Office on AIDS.
“What’s common to all of these recent approaches, including
post-exposure prophylaxis (PEP) and treatment as prevention
(TasP), is that they entail some form of behavior change, and
certain groups of people are going to have more difficulty
engaging in these change behaviors. We’re beginning to see an
increasing integration of mental and behavioral health that may
help in addressing these behavior-change difficulties, and HIV/
AIDS is leading the way down that road,” Martin says.
Psychologists can offer behavioral approaches to support
PrEP adherence, says Eugene Farber, PhD, professor at Emory
University School of Medicine, who helped draft the APA’s 2012
resolution on approaches to optimize HIV prevention.
“The evidence base shows that adherence is a key factor
in the success of PrEP. Therefore, psychologists have the
opportunity to contribute to optimizing the use of PrEP for
HIV prevention through research and by applying behavioral
strategies that help to maximize adherence,” he says.
Here are some of the barriers to adoption that therapists
may face, and ways some psychologists are approaching them.
Any biomedical protocol faces uptake challenges, particularly
those that require regular use, experts say. APA’s resolution
emphasizes “behavioral interventions that enhance knowledge
and build skills,” while incorporating attention to patient
factors, such as health conditions and substance abuse problems
— both key for populations at high risk for contracting HIV.
One intervention may be to help alleviate the stigma
associated with taking PrEP. Some in the gay men’s community
fear that the drug will invite promiscuity and unprotected sex.
Adam Zeboski, a 26-year-old who works at the San Francisco
AIDS Foundation, began a Twitter and T-shirt campaign,
#truvadawhore, co-opting a popular “slut-shaming” insult and
hoping to increase awareness of PrEP’s benefits. (For the record,
a 2013 study in PLOS ONE suggested that those taking it don’t
increase risky behavior. Zeboski says PrEP is a big cultural shift
from the days when being responsible meant only one thing:
Using a condom.
“The resistance to PrEP is coming from older folks who have
come through decades of HIV trauma and the thought of sex
equaling death,” he says. “Young gay men like me are interested
in exploring sexuality.”
Jeffrey Parsons, PhD, professor at Hunter College, says taking
a positive tack during therapy may alleviate some of the guilt
and anxiety that has accompanied sex for so long among high-
“I would say, ‘Think of the ways taking this medication
can improve your health and your sexual life.’ We need to get
pleasure back into the discourse. It’s what resonates with people,
particularly with a younger generation coming into a very
different kind of HIV world,” he says.
Manuel Rodriguez, who directs two national outreach
programs to increase HIV testing and HIV-prevention
communication among gay and bisexual men for the nonprofit
group FHI 360, says of PrEP, “Taking it, you feel empowered.
You feel in control of your sexuality by adding another layer of
protection. You start to break free of the fears that have haunted
you for all these years. Taking control of your health can have
positive ramifications on the rest of your life.”
Another important role for psychologists is recommending
PrEP in the first place when appropriate.
“We as psychologists see gay men who might be at risk,
and it’s incumbent on us to say, ‘This is something you might