Challenges of providing HIV pre-exposure prophylaxis across Australian clinics: qualitative insights of clinicians

Abstract

Background: HIV pre-exposure prophylaxis (PrEP) has been rapidly implemented in Australia, initially through restricted access in demonstration studies, and then through prescribing across sexual health clinics and general practice settings. In 2018, PrEP was publicly subsidised for people with Medicare (universal health insurance for citizens, permanent residents and those from countries with reciprocal arrangements). There is little research examining the experiences of PrEP providers in Australia, and existing research has been primarily conducted before public subsidy. Methods: In this qualitative study, we examine the challenges that have emerged for PrEP-providing clinicians after public subsidy for PrEP was introduced. We conducted 28 semi-structured interviews in 2019-20 with PrEP providers in two Australian states, and analysed data thematically. Participants included general practitioners (GPs), sexual health nurses and sexual health physicians. Results: Sexual health services have been reconfigured to meet changing patient demand, with an emphasis on ensuring equitable financial access to PrEP. Restrictions to nurse-led PrEP frustrated some participants, given that nurses had demonstrated competence during trials. GPs were believed to be less effective at prescribing PrEP, but GP participants themselves indicated that PrEP was an easy intervention, but difficult to integrate into general practice. Participants expressed discomfort with on-demand PrEP. Conclusions: Our findings indicate that supporting ways for patients without Medicare to access PrEP inexpensively, advocating for nurse-led PrEP, and developing guidelines adapted to general practice consultations could ensure that PrEP is delivered more effectively and equitably. Additionally, PrEP providers require encouragement to build confidence in providing on-demand PrEP.

How Do Family Physicians Perceive Their Role in Providing Pre-exposure Prophylaxis for HIV Prevention?–An Online Qualitative Study in Flanders, Belgium

“…We found that participants who anticipated not being confronted regularly with a demand for PrEP, perceived the investment of having to re-familiarize with PrEP on limited occasions too much of a burden. This barrier of a lack of demand experienced by some FPs was also reported in a study among PrEP-prescribing FPs in Australia ( 33 ). Alternatively, we found that some FPs expressed a particular interest in being able to initiate clients on PrEP without the need for referral.…”

Incorrect Knowledge of Event-Driven PrEP “2-1-1” Dosing Regimen Among PrEP-Experienced Gay and Bisexual Men in Australia

“…However, there were still reservations among some Australian clinicians to promote ED-PrEP because of beliefs that the regimen is confusing, less effective, or more difficult to use than daily PrEP, and that it is not a priority compared with discussing condoms, daily PrEP, and HIV testing. 42,43 Furthermore, although the Australian PrEP clinical guidelines endorsed ED-PrEP in 2019, daily PrEP is the only regimen approved by the Australian Therapeutic Goods Administration. 44 Regardless, even among those aware of the regimen, knowledge about how to take ED-PrEP was still low.…”

Prescribing as affective clinical practice: Transformations in sexual health consultations through HIV pre‐exposure prophylaxis

“…‘Sexual health nurse’ included registered nurse, clinical nurse consultant, clinical nurse specialist, and nurse practitioner. While most nurses (except nurse practitioners) cannot prescribe PrEP in Australia, we included nurses in our study as some were permitted to dispense PrEP during trials, and many continued to educate and assess patients for PrEP alongside prescribing clinicians (see Smith, Haire, et al., 2021). To ensure confidentiality when quoting participants, only their profession is reported, that is, [P01 – Sexual Health Nurse].…”

“…In Australia, PrEP was initially introduced in 2015, and made publicly available in 2018, available via prescription from a doctor or nurse practitioner (Smith, Haire, et al., 2021). Rapid scale‐up of PrEP in New South Wales, Australia demonstrated that PrEP can be successful in preventing HIV transmissions (Grulich et al., 2021).…”