Prescribers Hesitate on HIV PrEP

While health care providers generally favor pre-exposure prophylaxis (PrEP) for patients at high risk of acquiring human immunodeficiency virus (HIV), many hesitate to actually prescribe it.

The US Centers for Disease Control and Prevention (CDC) consider PrEP a proactive step for high-risk HIV-negative adults, such as mixed-status couples, gay men who don’t use condoms, and intravenous (IV) drug users.

HIV Specialist, a quarterly magazine from The American Academy of HIV Medicine (AAHIVM), recently published the results of a 53-question survey of 324 regional AAHIVM members, many of whom specialize in HIV.

The respondents rated 9 factors when considering prescribing PrEP as not at all important, somewhat important, and very important. The most common “very important” concerns were adherence, follow-up care for monitoring and counseling, and the effectiveness of PrEP in preventing HIV.

Medication cost was the next most common concern among providers from the South, Midwest, and West, while northerners were more concerned with side effects. Another regional difference was southern providers were more likely to be concerned about their patients engaging in riskier sexual behaviors as a result of taking PrEP.

About 79% of providers indicated they would be very likely to prescribe PrEP to gay men with an HIV-positive partner. At least half of respondents also said they would be very likely to prescribe PrEP to a gay man who has HIV risk factors, sometimes uses condoms, has a partner with unknown status, or has a history of sexually transmitted infections (STIs).

Alarmingly, less than half of providers said they would be very likely to prescribe PrEP to an IV drug user, heterosexuals with HIV risk factors, methamphetamine users, and gay men with an HIV-positive partner on highly active antiretroviral therapy.

“Providers’ reticence to prescribe to these groups may reflect beliefs about transmission risk behavior or concerns about the efficacy of PrEP for heterosexual patients,” the study authors wrote.

With only 49% of respondents saying they would be very likely to prescribe PrEP to an IV drug user, and only 44% indicating the same for methamphetamine users, providers showed concerns about adherence and monitoring of patients on PrEP who have active substance problems.

Although the majority of providers offered HIV and STI testing to patients engaging in high-risk behaviors, there were more mixed results regionally among those who offered the same testing to patients engaging in low-risk behaviors.

Despite practice guidelines specifying populations that would benefit from PrEP, some barriers prevent providers from fully endorsing and prescribing PrEP to patients, the researchers concluded. They suggested providers need more information about the use of PrEP, specifically for heterosexual individuals and drug users. In addition, providers may need more guidance on how to help patients overcome potential problems with drug adherence, cost, and monitoring.

“Our findings emphasize that health care providers need ongoing education and guidance about how to deal with practical issues associated with prescribing PrEP,” lead study author Leah M. Adams, PhD, a research fellow at Group Health Research Institute, said in a press release.

With roughly 50,000 new HIV infections each year in the United States, the CDC recommends that providers test all patients aged 13 to 65 years for HIV unless they opt out.

The vast majority of HIV transmissions originate from undiagnosed and untreated HIV-positive individuals, according to a recent study published in JAMA Internal Medicine.