The Promise of PrEP

This issue of the Journal of Gay and Lesbian Mental Health (JGLMH) features a collection of papers that we hope you will find useful in thinking about the meaning and impact of preexposure prophylaxis (PrEP) for your patients. The past few years of scientific study have brought into clarity the tremendous potential impact of PrEP on human immunodeficiency virus (HIV) transmission. Yet it is not just virologists and epidemiologists who should take an interest in these developments. Mental health providers and behavioral scientists also have an interest in what happens with PrEP. Dr. Darrell Tan, a PrEP researcher in Toronto who is a contributing author to this issue, puts it succinctly: “PrEP is not a purely biomedical thing. It's also a behavioural thing” (McCann, 2014).

PrEP is the provision of HIV treatment medications to HIV negative individuals in order to prevent infection. As the side effect profile and pill burden of HIV treatments have improved, some of the practical barriers to exploring the possibilities of PrEP have diminished considerably. In the United States, Gilead Sciences received the first Food and Drug Administration (FDA) approval for PrEP in 2012 for Truvada, its once-a-day combination of tenofovir and emtricitabine. In other jurisdictions like Canada, where the drug is already available for HIV treatment, many are being prescribed the medication off-label (McCann, 2014). Some of the first studies for PrEP involved serodiscordant couples, although interestingly, it may be equivalently effective to robustly treat the HIV-infected partner, a strategy known as Treatment as Prevention (TasP; Davis, 2012). A review of the important PrEP studies, by Luis Pereira, Simona Goschin, and Kenneth Ashley, starts off our special issue in order to give you the latest info about PrEP basics.

As you will read, one key aspect of successful PrEP is adherence. Mental health professionals are familiar with the concept of adherence and how it can be affected by comorbid mental health issues. This is true of adherence to HIV risk-reduction strategies, often affected by substance use (see, e.g., Halkitis, Green, & Carragher, 2006) as well as adherence to HIV treatment itself (Tsai et al., 2010). In this issue, Adriana Carvalhal, Darrell Tan, Marisa Leon-Carlyle, and Roseanne Mills present a case series of men who have sex with men (MSM) who were screened for psychiatric concerns on admission to a PrEP clinic, and describe their rationale for recommending such screening be routine.

Of course individuals will not present to PrEP clinics if they do not know about them. Roland Merchant, David Corner, Eduardo Garza, Wentao Guan, Kenneth Mayer, Larry Brown, and Philip Chan present a pilot survey of preferred methods for obtaining information about PrEP in their sample of Rhode Island residents attending a Pride festival. Finally, David Goldenberg provides some insights from his private psychotherapy practice on the impact of PrEP on individuals from different cohorts of gay men.

It may be early days yet to assess the total impact of this new HIV prevention tool for the epidemic. While we seem to have a relatively good answer to the question of whether PrEP works (yes, given good adherence), there are still quite a few questions left to answer. While some of the PrEP studies have included trans women who have sex with men, we know little about what trans men think of PrEP and its possibilities for their HIV prevention efforts. What about bisexual women? How are members of our community using PrEP in real world settings? How can we increase access to PrEP for those who want it, and the acceptability of PrEP to those who need it? Could PrEP have side benefits for our patients with sexual anxiety? Perhaps in a few years there will be some answers to these questions and we will be able to have another special issue on this important topic.

Elsewhere in this issue, Molly Kingdon, Staci Barton, Jessica Eddy, and Perry Halkitis present their paper on a related topic: barriers to HIV status disclosure in a cohort of older gay and bisexual men. Jennifer Robinson and Linda Rubin present a study on the relationship between homophobic microaggressions and posttraumatic stress disorder symptoms, and Geva Shenken and Dov Shmotkin present their work exploring the connection between mental health symptoms and a “hostile world scenario” in lesbian, gay, bisexual, and transgender (LGBT) people.

Our Oral History series, which presents interviews with prominent individuals from the lesbian, gay, bisexual, transgender, and questioning (LGBTQ) mental health community, continues with an insightful interview by JGLMH Editor Emeritus Jack Drescher of clinical psychologist and prominent LGBTQ ally George Weinberg. Dr. Weinberg is perhaps most famous for coining the term “homophobia” in his 1972 book Society and the Healthy Homosexual (Weinberg, 1972).

We are delighted to welcome our new book editor to the JGLMH team this issue. Rebecca Hopkinson is a child and adolescent psychiatrist who completed both her medical education and her psychiatry residency training in New York, at Columbia University and New York University, respectively. She continued on to complete her Child and Adolescent Psychiatry Fellowship at the University of Washington, at Seattle Children's Hospital, where she currently works as faculty. Her academic interests include LGBT mental health, refugee and asylum seekers, and psychotherapy, including dialectical behavior therapy. This issue we also present the first book review under her tenure, Joshua Kellison's review of the first book in a new series, Annals of Gay Sexuality: The Contemporary HIV Zeitgeist.