When Daily Oral PrEP Is Not the Best Fit: Lessons From Clinical Practice

Clinical logic doesn't always align with patient psychology—a lesson Kevin Hatfield, MD, a family medicine and primary care physician, learned powerfully through a patient case that initially baffled him. The patient was a man already taking eight different medications daily for various chronic conditions. When Hatfield recommended adding oral PrEP for HIV prevention, he anticipated the patient would simply incorporate it into his existing routine. After all, what difference could one more pill make when you're already taking eight?

But for this patient, adding a ninth pill represented an insurmountable psychological barrier. He drew a firm line in the sand, refusing to add another tablet to his daily regimen despite understanding the importance of HIV prevention and despite his risk profile clearly indicating need for PrEP. From Hatfield's medical perspective, the distinction between eight and nine pills seemed arbitrary and insignificant. Yet this patient's resistance remained absolute.

The impasse resolved completely when Hatfield introduced the option of long-acting injectable PrEP. The patient's response was immediate and enthusiastic: "Sign me up." He has remained successfully adherent to his injection schedule ever since, receiving his shots every two months without hesitation. The injectable bypassed his psychological ceiling around pill burden while providing the same level of protection.

This case reinforced a critical clinical principle for Hatfield: patient-centered care means honoring what works for the individual, even when it doesn't align with the provider's logical framework. The lesson extends beyond HIV prevention to all therapeutic decisions. Providers must resist the temptation to dismiss patient preferences that seem medically illogical, recognizing instead that sustainable treatment plans must accommodate each patient's unique psychological relationship with medication.

The shared housing patient case, revisited in this segment, provides another compelling example. Her refusal of oral PrEP wasn't about efficacy concerns or side effects—it was about protecting her privacy in a living situation where a prescription bottle could expose personal health decisions to housemates she wasn't prepared to confide in.

Patient Care: Can you describe a specific patient case for whom switching to long−acting injectable PrEP was transformative, and what made that difference for them?

Hatfield: I alluded a little bit to this one patient who was living in shared housing and was just very concerned that her housemates would see that she had HIV prevention tablets in the house. Another patient that I can think of was a gentleman who basically was having a really hard time taking a lot of other medications. He was doing a pretty good job. He had some medicines for a variety of different conditions, and a sum total of 8 medicines that he was taking. And for him, it was very interesting, because from my perspective, if you're taking 8 tablets every day, what's the difference between taking 8 and 9? But there was a line in the sand for him. And so he was also very resistant to adding an HIV medication for prevention to his eight−tablet−a−day existing regimen. And so for him, he was dragging his heels to take steps for prevention. And when I said, "You know, there's a long−acting injectable available," he was like, "Great. Sign me up. That's wonderful." And he's been really happy with that.

The interesting thing from my perspective as the prescriber was 8 versus 9 pills—there's no difference, right? But from his perspective, it was not even an option to take one more tablet every day. So I think that was enlightening for me, because once again, it circles back to what fits best for the patient. And so soliciting his opinion—although it didn't make sense for me, the way he was framing it—it totally was what worked for him, and it's been successful ever since.

The transcript was edited lightly for clarity and flow.