A Qualitative Study of Provider Thoughts on Implementing Pre-Exposure Prophylaxis (PrEP) in Clinical Settings to Prevent HIV Infection

Abstract

BackgroundA recent clinical trial demonstrated that a daily dose tenofovir disoproxil fumarate and emtricitabrine (TDF-FTC) can reduce HIV acquisition among men who have sex with men (MSM) and transgender (TG) women by 44%, and up to 90% if taken daily. We explored how medical and service providers understand research results and plan to develop clinical protocols to prescribe, support and monitor adherence for patients on PrEP in the United States.MethodsUsing referrals from our community collaborators and snowball sampling, we recruited 22 healthcare providers in San Francisco, Oakland, and Los Angeles for in-depth interviews from May-December 2011. The providers included primary care physicians seeing high numbers of MSM and TG women, HIV specialists, community health clinic providers, and public health officials. We analyzed interviews thematically to produce recommendations for setting policy around implementing PrEP. Interview topics included: assessing clinician impressions of PrEP and CDC guidance, considerations of cost, office capacity, dosing schedules, and following patients over time.ResultsLittle or no demand for PrEP from patients was reported at the time of the interviews. Providers did not agree on the most appropriate patients for PrEP and believed that current models of care, which do not involve routine frequent office visits, were not well suited for prescribing PrEP. Providers detailed the need to build capacity and were concerned about monitoring side effects and adherence. PrEP was seen as potentially having impact on the epidemic but providers also noted that community education campaigns needed to be tailored to effectively reach specific vulnerable populations.ConclusionsWhile PrEP may be a novel and clinically compelling prevention intervention for MSM and TG women, it raises a number of important implementation challenges that would need to be addressed. Nonetheless, most providers expressed optimism that they eventually could prescribe and monitor PrEP in their practice.

Clinician Attitudes Toward CDC Interim Pre-Exposure Prophylaxis (PrEP) Guidance and Operationalizing PrEP for Adolescents

“…Similar to findings in other studies, [22][23][24][25][26][27] we found variability in clinician reports of PrEP target populations. Clinicians were explicit in reporting which patients would be eligible for PrEP, including patients who are members of specific populations who are at high risk of HIV infection, as well as those able to access and adhere to PrEP and PrEP monitoring.…”

Adolescent Human Immunodeficiency Virus Care Providers’ Attitudes Toward the Use of Oral Pre-Exposure Prophylaxis in Youth

“…[12][13][14][16][17][18] Participants were divided as to whether they thought risk compensation (increases in risky sexual behaviors after the initiation of PrEP) would occur. Although concerns about risk compensation have been raised by some adult care providers, 12,13,[16][17][18][19][20] studies to date suggest that the majority of people taking PrEP do not practice risky behaviors. [31][32][33] Few participants were concerned about prescribing PrEP for off-label use to a minor-aged patient.…”

“…MSM are considered by clinicians to be potential candidates for PrEP, 9 and studies have demonstrated that PrEP is an acceptable intervention to young MSM, 10,11 However, for PrEP to be an effective intervention, healthcare providers must be willing to prescribe this medication to youth. Potential providers of PrEP to adults have described a variety of concerns related to PrEP, including concerns about adherence, [12][13][14][15][16] development of viral resistance with incomplete adherence, 12,[14][15][16][17][18][19][20] high cost and insufficient coverage by insurance, 12,14,16,19,20 medication toxicity 12,14,17,18 and side effects, 16,17,19 efficacy outside of a clinical trial setting, 13,14,17,20 and risk compensation. 12,13,[16][17][18][19][20] In addition to these concerns, the provision of PrEP to youth may present unique challenges related to the ability of minor adolescents to access PrEP without parental consent.…”

A Cross-Sectional Online Survey of HIV Pre-Exposure Prophylaxis Adoption Among Primary Care Physicians

“…The PCP PrEP Survey was informed by a literature review of health care providers' PrEPrelated knowledge, attitudes, and behaviors, [11][12][13][14][15][16][21][22][23][25][26][27][28][29][30][31][32] an existing survey instrument, 33 and feedback from community members involved in HIV prevention research. It was developed and pilot-tested in an iterative fashion by the authors, most of whom are PCPs who provide HIV care and/or researchers who conduct HIV bio-behavioral research (Online Appendix).…”

“…Additionally, PCPs primarily deliver care to HIV-negative individuals, some of whom may be at substantial HIV risk, and therefore PrEPeligible. 17,19 Despite the potentially important role of PCPs in implementing PrEP (i.e., incorporating PrEP into clinical practice), earlier studies of providers' PrEP-related attitudes and potential role in PrEP adoption (i.e., commitment to and initial use of PrEP, defined in this study as a prescription of or referral for PrEP) 20 have focused mainly on HIV specialists, 12,15,[21][22][23][24] such as infectious disease (ID) physicians, and/or have been limited to specific geographic regions of the U.S. 13,16,[25][26][27][28][29] No published studies of PrEP adoption have focused exclusively on general internists, which is notable, given that they are abundant, geographically distributed throughout the U.S., and uniquely positioned to offer PrEP to persons at high risk of HIV infection.…”