Widespread support for HIV PrEP among infectious disease doctors in the US and Canada

Few have ever prescribed PrEP

Michael Carter
Published: 17 December 2013

Three-quarters of 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.

“Strong support 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 discontinued.”

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.

Investigators 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 practice.

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 behaviors artificially.”

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 intervals.

The biggest 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.

“Despite CDC 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 cost-effectiveness.”

Reference

Karris MY et al. Are we prepped for PrEP? Provider opinions on the real-world use of PrEP in the U.S. and Canada. Clin Infect Dis, online edition, 2013.