Providers Hesitant to Prescribe Pre-Exposure HIV Preventative Regimen

HIV antiviral therapy can prevent infection from establishing in at-risk individuals.

Individuals who face a significant risk for contracting HIV may face a difficult path to gaining a prescription for a preventative HIV treatment regimen, a recent survey indicates.

The survey, published in the journal HIV Specialist, notes that health care providers throughout the United States may be hesitant to prescribe a preventative approach for patients with an ongoing substantial HIV risk. This proactive treatment approach, called pre-exposure prophylaxis (PrEP), includes prescribing an HIV antiviral drug regimen for uninfected people in an effort to prevent the disease from establishing and multiplying within the body.

The survey included 53 questions of 324 American Academy of HIV Medicine members. Less than half of the respondents indicated they were very likely to prescribe PrEP to high-risk heterosexuals or intravenous drug users.

"That's concerning, because these groups are among the prime candidates for PrEP according to the guidelines," first author Leah M. Adams, PhD, said in a press release.

Meanwhile, 79% of providers indicated they were very likely to prescribe the regimen for HIV-negative men with male partners infected with HIV.

"HIV-negative men in 'serodiscordant' couples were the most likely group to be prescribed PrEP in our sample," co-author Benjamin Balderson, PhD, said in a press release. "But that still leaves 21% of respondents who were not very likely to prescribe PrEP even to people in this group. Academy members are likely very aware of the indications for thinking about PrEP in this population, but something is still making them reluctant to prescribe."

The primary reasons providers identified as the source of their reluctance to prescribe the regimen included:

• Patients consistently taking a daily pill
• Regular follow-up care for monitoring and counseling
• Effectiveness of PrEP in preventing HIV
• Side effects
• Patients engaging in riskier behaviors (compensating for assuming that PrEP would completely protect them)
• Cost of treatment

"Initial concerns about an increase in risky behavior, side effects, drug resistance, and adherence made providers reluctant to prescribe PrEP," co-author Kathy Brown, MD, said in a press release. "But the evidence base for PrEP use is strong--and getting stronger. Recent "real-world" studies (not clinical trials) of PrEP use do not support these concerns."

The cost of the regimen is also a problem, the survey indicated. To date, the only PrEP approved by the FDA is the combination of antiretroviral medications tenofovir and emtricitabine (Truvada). The drug combination costs $14,400 per year, while lab costs for routine monitoring are $180 per year.

"Treatment has helped to turn HIV infection into a chronic disease in most cases, and people living with HIV are more often seeing primary care providers instead of infectious disease specialists," Dr. Adams said. "But too many people have the mistaken impression that the HIV epidemic is over."

Furthermore, the rate of new HIV infections in the United States over the past decade has held steady at approximately 50,000 new cases per year.

"PrEP promises to help to curb the rate of new HIV infections as part of a comprehensive prevention plan--including safer sex, regular 'opt-out' HIV testing, risk reduction counseling, and treatment of any other sexually transmitted infections," Dr. Balderson added.

In placebo-controlled clinical trials, PrEP was found to be a safe and effective tool in the prevention of HIV infection in men who have sex with men, high-risk heterosexuals, and in couples where one partner is living with an HIV infection.

"Our findings emphasize that health care providers need ongoing education and guidance about how to deal with practical issues associated with prescribing PrEP," Dr. Adams said.