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Pre-Exposure Prophylaxis (PrEP) is a once-daily prescription medicine, approved by the US Food and Drug Administration (FDA) in July 2012, that can help HIV-negative individuals reduce their risk of acquiring HIV when it is taken every day and used together with safer sex practices.
PrEP is endorsed by the US Centers for Disease Control and Prevention (CDC) as a science-driven public health approach to what remains a major health crisis in the United States. Used along with other preventive strategies, PrEP has the potential to help individuals at risk for HIV infection to protect themselves and, ultimately, to reduce HIV incidence. However, implementation of PrEP has been relatively slow to date and faces numerous and multifactorial barriers, as detailed below.
This piece is part of an ongoing needs/gap assessment evaluating barriers and unmet needs in HIV PrEP implementation as a part of an overall HIV prevention strategy. It is based on a quantitative survey, administered online from June 30 to July 14, 2017 using SurveyMonkey[TM]. The survey gathered attitudes toward and knowledge of PrEP for HIV prevention among medical providers.
Other needs assessment entries will detail findings of a literature review, qualitative surveys of clinicians and patients, and a quantitative survey of patients.
This needs assessment is part of a larger initiative called Let’s Get Real About PrEP provided under the auspices of Albert Einstein College of Medicine and NovaMed Education Inc. with program contribution from HealthHIV. This program is supported by an educational grant from Gilead Sciences.
Dr. Bisola Ojikutu of Massachusetts General Hospital and Dr. David Hardy of Whitman-Walker Health provided technical development advice and review of the survey and its findings.
- 145 healthcare providers responded to the survey
- 67% of providers are White and 57% practice in either a hospital, specialty clinic, or Federally Qualified Health Center (FQHC)
- Approximately 2/3 of the providers offer PrEP to all adults who may be at risk for HIV. Only 1/3 offer PrEP to young men who have sex with men under the age of 18
- 70% of prescribing providers report having a basic understanding of PrEP, but only half are aware of the timeframe during which PrEP becomes effectively protective against HIV
- There is a notable gap between the number of providers who would discuss sexual health history with a gay patient and those who would discuss this topic with a heterosexual patient
- 50% of providers note a concern that PrEP decreases kidney function
Unless otherwise noted, the term “provider” is used to describe MD/DO/NP/PA respondents throughout this report.
66% of all survey respondents identify as White/Caucasian and 89% identify as non-Hispanic.
Of all respondents, 46% are prescribing providers, including 25% MD/DO, 15% APRN and 5% Physician Assistant. Other respondents included 14% RNs 9% social workers or counselors and 32% “other.” Respondents who marked “other” are health educators, people who hold an MPH degree, and PrEP peer educators and insurance navigators.
Among all respondents, ages ranged from 18 to 74 years, with the largest percentage falling between the ages of 45 and 54 years. 29% of respondents reported practicing medicine for 21 years or longer, while 21% reported practicing 5 to 10 years. 38% of the providers who prescribe PrEP have practiced medicine for more than 20 years.
54% of providers are HIV Medicine or Family Medicine providers, and 41% work in a hospital or clinic. 45% of providers are considered primary care providers (PCPs). 28% work in a Federally Qualified Health Center (FQHC). 66% of providers work in urban jurisdictions. 50% of providers saw 51-150 patients in the past month. 49% of providers report that 25% or fewer of their patients are African American or Hispanic/Latino men who have sex with men.
79% of all respondents work at an agency that provides PrEP services and 78% of providers personally prescribe PrEP.
81% of providers in urban settings and 80% of providers in suburban or rural settings prescribe PrEP. 78% of PrEP prescribers are White/Caucasian, 9% are Black or African American and 9% are Asian/Pacific Islander. 56% of PrEP prescribers are MD/DOs.
Among the providers who prescribe PrEP, 95% report that they prescribe to HIV-negative individuals in serodiscordant relationships, 93% report to prescribe PrEP for men who have sex with men (MSM), and 73% report prescribing PrEP to male-to-female transgender patients. Over half of providers provide PrEP to active injection drug users, female-to-male transgender patients, and patients with any non-HIV STI diagnosis. 32% of providers offer PrEP to MSM who are younger than 18 years old. Each of the above-mentioned client populations are at elevated risk for HIV according to the CDC, and are therefore candidates for PrEP.
It is noteworthy that only about 1/3 of providers offer PrEP to young MSM (aged 13-18, especially because these persons face disproportionately high rates of HIV infection. Young Black and Latino MSM both saw increased new infections of about 87% from 2004-2014.[i]
Almost all providers who prescribe PrEP correctly answered the basic knowledge questions, including knowledge of common side effects, rapid HIV tests inability to detect antigens associated with acute HIV infection, and PrEP’s 90%+ effectiveness when taken daily.
However, 24% of PrEP providers and 59% of non-PrEP providers do not know the timeframe during which PrEP becomes maximally protective against HIV for individuals engaging in receptive anal sex. The CDC has published that this time period is 7 days.[ii] 43% of PrEP providers and 66% of non-PrEP providers do not know when PrEP becomes maximally protective against HIV for individuals engaging in insertive anal sex, vaginal sex, and injection drug use—published by the CDC to be 20 days—and those who got this wrong underestimated the time period, which is a serious concern.
Generally, providers who do not prescribe PrEP scored lower on the basic PrEP knowledge questions compared with prescribing providers. Non-providers scored lower on general knowledge questions than clinical providers. The chart below compares knowledge of antibody testing capabilities by type of provider.
PrEP in Practice
When asked if they would discuss HIV prevention with a 52-year-old heterosexual woman who was recently divorced from her long-time monogamous partner, 70% said “yes.” All providers said they would discuss HIV prevention methods with her after finding out that she had recently had unprotected sex with multiple partners. It is concerning that 20% of providers indicated that they would not have discussed HIV prevention with the woman had she not proactively discussed her recent sexual history.
96% of providers would take a sexual history with a man who has been married to his male partner for 4 years. After the man explains that he is HIV-negative and recently found out that his HIV-negative partner has had sex with 5 other partners in the past year, 94% of providers would offer him PrEP. If the man had not brought up his partner’s sexual history, 14% of providers would not have discussed HIV prevention with him, a concerning knowledge and history-taking gap.
Given no other indications, the 26% of providers who would discuss HIV prevention with a gay man, but not with a middle-aged heterosexual woman, unless alerted to risk factors, indicates bias based on sexual orientation and/or perceived risk. Providers are more comfortable discussing sexual history and risk factors for acquiring HIV with a patient they know or suspect has sex with men than with someone whom they assume is having sex with fewer partners. Among non-prescribing providers, 17% reported that they would not discuss HIV prevention with the heterosexual woman and 20% reported that they would not discuss HIV prevention with the gay man unless prompted by disclosure of his recent sexual history. This is also concerning as these providers are often in a position to help elicit relevant patient history.
Views and Concerns
Over 70% of providers agree that their patients can consistently take a daily pill, can engage in PrEP follow-up care, and 58% agree that their patients can afford costs associated with taking PrEP.
90% of providers agree that they have enough time to provide the prevention counseling and monitoring required to support PrEP. 84% of providers disagree that patients should be able to receive PrEP without seeing a provider. 78% agree that PrEP is more effective at preventing HIV than non-biomedical prevention methods.
50% note a concern about PrEP’s effects on kidney function; the CDC 2014 PrEP guidelines do incorporate renal testing prior to prescribing PrEP and as part of routine follow-up testing.[ii] 94% of providers believe that insurers should provide PrEP coverage. 90% feel comfortable discussing HIV risk factors like sexual behaviors and injection drug use with their patients. 70% of providers state that they routinely conduct a thorough sexual history with patients.
22% of providers believe that PrEP use will lead to HIV drug resistance, which constitutes a knowledge gap. 47% believe that PrEP will lead to an increase in STI incidence, which is as expected based on recent reports from high-volume PrEP prescribing centers as well as increased routine STI screening of asymptomatic patients who are on PrEP. 18% of providers are not comfortable or familiar with providing the quarterly pre-approval documentation to insurance companies that is sometimes necessary for PrEP coverage.
72% of providers are familiar with iPrEX, iPERGAY or Partners PrEP, some of the foundational research studies on PrEP effectiveness. 92% of providers are familiar with the 2014 CDC PrEP Guidelines. 86% reported that they would be comfortable prescribing PrEP to a patient who uses condoms during sex, but who would like to reduce their condom use.
69% of providers believe that patients on PrEP are more likely to have more condomless sex, but 73% of providers agree that PrEP patients are more likely to discuss HIV status with their partners. 92% do not believe that patients would increase injection drug use and 76% do not believe patients would increase use of substances like alcohol or amphetamines when engaging in sex. 53% of providers believe that patients on PrEP will have more sexual partners.
All providers are at least somewhat confident in their ability to conduct bi-annual STI testing, quarterly HIV testing, screening for acute HIV infection and conducting adherence counseling with their patients on PrEP. 2% are not confident that they understand the differences between nPEP and PrEP. In the open comments sections, many providers noted concern that common barriers to PrEP are affordability and accessibility.
Providers who responded to this survey are generally aware of PrEP. They generally accept that PrEP is an effective HIV prevention method, but many—even PrEP prescribers—still are unaware of basic PrEP facts. Additionally, providers who do not prescribe PrEP are more likely to believe that patients will increase engagement in HIV risk behaviors after starting on PrEP.
PrEP has been approved by the FDA for HIV prevention for persons at risk 18 years of age and older, so many providers may not feel comfortable prescribing it to youth under the age of 18 years. The only pediatrician respondent of this survey has been prescribing PrEP for three years, but the 67% of providers who do not offer PrEP to young MSM, despite their high risk for HIV, indicates a need for provider education on the effects of PrEP prescription for young MSM. It also reflects a lack of FDA approval for PrEP in this age group as well as data suggesting that PrEP may decrease bone mineral density in young men.[iii]
The findings indicate that increased provider awareness is needed on the timeframes during which PrEP becomes effective at preventing HIV transmission associated with specific sexual acts. The ongoing body of research measuring the relationship between PrEP use and risk compensation continues to unfold as the roll-out of PrEP expands. How these data describe this phenomenon will continue to be the subject of ongoing educational need.
[ii] Centers for Disease Control and Prevention. Pre-exposure prophylaxis for the prevention of HIV infection in the United States – 2014: clinical practice guideline. Available at: https://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf. Accessed July 1, 2017.
[iii] Grant R, Mulligan K, McMahan, et al; iPrEx Study Team. Recovery of bone mineral density after stopping oral HIV preexposure prophylaxis. In: Program and abstracts of the 2016 Conference on Retroviruses and Opportunistic Infections; February 22-25, 2016; Boston. Abstract 48LB.
Copyright Albert Einstein College of Medicine and NovaMed Education Inc. 2017.