infectious disease specialists in the United States and Canada are supportive
of HIV pre-exposure prophylaxis (PrEP), but only 9% have prescribed the treatment,
results of a survey published in the online edition of Clinical Infectious Diseases show. The study is the largest-ever
survey of physician attitudes towards PrEP.
exists for PrEP but very few clinicians (9%) have actually provided it,”
comment the authors. “Additionally, a wide range of PrEP practices existed
among those who have or would give PrEP including differences in deciding who
is eligible for PrEP, how persons on PrEP are followed-up and how PrEP is
PrEP has been
shown to reduce the risk of infection with HIV in certain at-risk populations.
The US Centers for Disease Control and Prevention (CDC) has published guidance documents
concerning eligibility for PrEP, and how to begin, monitor and cease therapy.
wished to assess the opinions of infectious disease specialists about PrEP and
their current prescribing practices.
In June 2013, a
ten-part questionnaire to evaluate current PrEP attitudes and practices was
therefore distributed to 1175 physicians who were members of the Infectious
Disease Society of America’s (IDSA) Emerging Infections Network (EIN). There
was a 49% response rate.
A clear majority
(74%) of physicians supported PrEP. However, significant minorities were either
unsure (14%) or unsupportive (12%) of the therapy.
Only 9% of
respondents stated they had supplied PrEP. A further 43% said they had not yet
prescribed PrEP but would, and 34% indicated that PrEP was not relevant to their
Common reasons for
unwillingness to prescribe PrEP included fears about adherence and resistance,
concerns about cost and reimbursement, reluctance to use a potentially toxic
medication in healthy people and reservations about efficacy. Some physicians
raised concerns about risk compensation and there were occasional “moral”
objections, one physician stating: “Medicine should not attempt to reverse bad
Doctors who had or
would prescribe PrEP were asked questions regarding its use in the 'real world'.
Most said they would provide PrEP to people with risk factors for infection
with HIV. The main such factor was having an HIV-positive partner who was not
on antiretroviral therapy (89%), followed by reporting unprotected sex (61% if
the patient was heterosexual; 79% if MSM) and multiple sexual partners (59% if
the patient was heterosexual; 74% if MSM). Approximately a third of physicians
stated they would be willing to prescribe PrEP to injecting drug users.
Overall, 85% of
doctors said they would use nucleic acid testing (NAT) to screen for recent HIV
infection before someone started PrEP. Most providers (89%) stated they would
monitor adherence once treatment was started. The preferred method for
assessing treatment compliance was patient self-report (81%) and almost
three-quarters of doctors indicated adherence would be monitored at quarterly
perceived barriers to prescribing PrEP were cost, followed by concerns about
resistance, side-effects, efficacy and pressure on clinic time. One doctor
suggested that the “bigger bang for the buck is getting all the HIV-positive
patients on ART and keeping them adherent”.
Even doctors who
provided PrEP were not totally convinced about its use. One commented: “This
will never impact the overall incidence of HIV in the US,” whereas another was
unconvinced about the data showing the therapy’s efficacy.
guidance documents, great variability exists in the real-world practice of PrEP
suggesting either unawareness of, disagreement with, or ambiguity in CDC
guidance,” comment the authors. “The results of this survey and the additional
comments provided by participants have highlighted the importance of future
studies that specifically address the efficacy and risk compensation that
occurs in open-label PrEP, the development of point-of-care objective adherence
measures, description of the long-term consequences of PrEP in HIV-negative
persons, and design of successful and ‘resource-light’ approaches to risk
reduction and adherence counseling, and novel approaches to improving PrEP