Gilead expert calls for wider HIV PrEP uptake in Korea amid stigma, slow adoption

HIV pre-exposure prophylaxis (PrEP) has been hailed as one of the most effective tools in reducing new HIV infections worldwide.

Yet in Korea, uptake has been slow, constrained by systemic barriers and lingering social stigma. While the Korea Disease Control and Prevention Agency (KDCA) began a pilot project in late 2024 to subsidize PrEP costs, participation remains modest, with about 120 hospitals participating and only around 100 applicants enrolled in the first quarter of this year.

The program nonetheless marks a turning point. For the first time, physicians outside infectious disease departments -- such as family medicine, obstetrics and gynecology, and urology -- are being encouraged to prescribe PrEP.

Experts say this expansion of providers could normalize PrEP access and ease bottlenecks. But the challenge now lies in equipping frontline physicians to discuss sensitive issues like sexual orientation, gender identity, and high-risk behaviors in a supportive and non-judgmental way.

Gilead Sciences Executive Director of Global Medical Affairs for Virology Dr. Christian B. Ramers explains how U.S. lessons on PrEP can help guide Korea’s efforts during an interview with Korea Biomedical Review at Gilead Sciences Korea headquarters in Jung-gu, Seoul, in July. (Credit: Gilead Sciences Korea)

To explore how Korea can advance PrEP effectively, Korea Biomedical Review spoke with Dr. Christian B. Ramers, an infectious disease and addiction medicine expert from the U.S. who now serves as Executive Director of Global Medical Affairs for Virology at Gilead Sciences. Drawing on both clinical and policy perspectives, he offered insights from the U.S. experience and what they could mean for Korea.

Ramers pioneered HIV prevention education in the U.S., including the launch of HIV Tele-ECHO, the country’s first remote mentoring program for clinicians treating at-risk populations. His work emphasizes not only clinical guidance but also skills in trauma-informed care, cultural humility, and stigma reduction.

During his recent visit to Korea following the International AIDS Conference in Rwanda, he delivered a special lecture to Korean physicians titled “How to Hear a Secret,” aimed at helping Korean physicians navigate difficult conversations with patients who may need PrEP but hesitate to seek it openly.

From slow uptake to wider access

Ramers recalled that PrEP use in the U.S. was initially sluggish after its 2012 approval.

Primary care doctors considered it too complicated, while infectious disease specialists viewed prevention as outside their scope.

“It wasn’t until the CDC issued clear guidelines in 2014 that momentum picked up,” Ramers said. Since then, the U.S. has expanded access through multiple channels -- mobile clinics, telemedicine, even online prescription services.

Today, around 30 to 40 percent of the estimated 1.2 million Americans who need PrEP are using it.

Another major breakthrough was the introduction of long-acting injectable PrEP. Unlike daily oral pills, injections every two to six months reduce the fear of being outed by medication bottles and alleviate adherence challenges.

“Stigma is invisible but powerful,” Ramers said. “For many, not having to take a daily pill in secret is the difference between accessing prevention and avoiding care altogether.”

Insurance coverage and cost-effectiveness evidence also played a decisive role. The U.S. Preventive Services Task Force awarded PrEP its highest grade, recognizing that preventing HIV is far less costly than a lifetime of treatment. As a result, insurers are required to cover PrEP, ensuring access across income levels.

However, when the definition of high-risk groups expanded -- including people with sexually transmitted infections -- the potential population rose to 2 million.

As a result, even though the absolute number of PrEP users kept rising, the share of people covered among those who needed it -- what experts call the “relative coverage rate” -- actually fell.

In other words, more people were taking PrEP, but because the pool of people considered eligible had grown even larger, Ramers stressed that the overall percentage is probably lower than 30 to 40 percent.

“UNAIDS has suggested that at least half of those at risk need to be on PrEP to see meaningful declines in new infections,” Ramers noted. “This means that the U.S. is not yet at a point of decline.”

One major barrier is stigma. Daily oral PrEP pills risk being exposed to family or peers, discouraging some from starting.

While not yet available in Korea, the U.S. recently approved injectable PrEP administered every two months, and more recently a formulation lasting six months.

Ramers believes this could be transformative.

“For young, healthy people who don’t want to be labeled, long-acting injectables are game-changing,” he said. “They allow protection without the daily reminder or fear of being outed.”

Beyond medication to trust and dialogue

For Korea, where annual new HIV infections hover around 1,000, PrEP uptake is still in its infancy.

Yet access hinges on healthcare providers. In Korea, the pilot program now involves not only infectious disease specialists but also family physicians, gynecologists, and urologists.

Ramers welcomed this diversification.

“Restricting PrEP to a few specialties limits its reach, as patients need to feel they can walk through any door and receive it,” he said. “That’s what we call the ‘No Wrong Door’ approach in the U.S.”

This shift also requires cultural competence.

Many clinicians, in Korea and abroad, were never trained to discuss sexual orientation or gender identity in medical school. Ramers emphasized that building trust is central and stressed that the key lies not just in medication supply but in physician training and public awareness.

He noted that patients often hesitate to seek prescriptions for fear of being stigmatized by medical staff, or resort to unsafe, unofficial drug sources.

“Doctors need to create an environment where patients feel respected and safe,” he emphasized.

His lecture “How to Hear a Secret” walked physicians through practical strategies -- designing trust-based conversations, avoiding microaggressions, standardizing the collection of sexual orientation and gender identity data, and applying trauma-informed approaches.

“When patients can share their most difficult secrets in the exam room, that alone can be a turning point in care,” he said.

He also pointed to international campaigns as models. In the U.S., the pleaseprepme.org platform helps users find nearby clinics, while China has used the gay social network Blued to reach tens of millions with PrEP education. In Africa, peer-based programs -- where people learn about PrEP from trusted community members -- have proven particularly effective.

Looking ahead, Ramers said Korea’s pilot program is on the right track but must expand further to make PrEP as accessible as any other routine health service.

“The HIV field has gone from despair to hope in just a few decades,” he said. “Prevention is now in our hands and once physicians overcome the initial hesitation, they realize how simple and rewarding it is.”

Unlike traditional medicine where doctors fight disease after it appears, PrEP allows physicians to protect health from the start and that’s a deeply fulfilling role for any doctor, he added.