A survey of Italian infectious disease physicians working with HIV, conducted in 2015 but only published this July, reveals that at that time there was still considerable scepticism about HIV pre-exposure prophylaxis (PrEP).
The study data were collected in April and May 2015, two months after the results of the PROUD and IPERGAY studies were announced, but a year before the European Medicines Agency (EMA) approved PrEP.
At this point, the attitudes of the physicians polled – who form a substantial proportion of Italian doctors working with HIV – appeared to be in transition or even contradictory. While over half of them considered that health authorities had an ethical obligation to prescribe PrEP if needed, less than 30% thought it should be paid for by the national healthcare system. And while over 60% said that at least one of their patients had asked about PrEP, only a third said they were “familiar” with it.
In Italy, HIV treatment is conducted primarily by infectious disease physicians in HIV care centres based in hospitals. At the time of the survey there were 153 HIV Care Centres in Italy altogether but the questionnaire was sent to doctors in 50 centres with more than 500 patients each. The mean number of patients in Italian HIV care centres was in fact at that time 624, with a small number of large centres (HIV patient numbers ranging from 17 to 6526). It was assumed at this time that PrEP would also be dispensed by experienced HIV physicians, an assumption 63% of survey respondents agreed with.
Altogether 164 physicians completed the survey, 49% from northern Italy, 23% from central Italy, and 28% from the south. This forms a large majority of the estimated 200 physicians in Italy prescribing antiretroviral therapy (ART) who have more than 500 patients. Most physicians were highly experienced with HIV, with 58% being in practice for more than 15 years. Physicians in the north on average had more years of experience than physicians in the south and were more likely to be based in university teaching hospitals.
Despite this length of experience, 65% of physicians said they were not “familiar” with PrEP though attitudes were different in southern Italy, where only 35% said they were not familiar with it.
At the time of the survey, only 36% of physicians were satisfied that enough evidence now existed to make PrEP available in Italy; nearly half (47%) thought there was not enough evidence and 17% were undecided.
While 56% said health authorities had an ethical obligation to prescribe PrEP if needed, only 31% agreed with the statement that “PrEP is an innovative HIV prevention tool and should be made available in Italy as soon as possible.” Forty-five per cent disagreed with this statement (and 54% working in non-teaching hospitals), with 24% undecided. When presented with a question posing the opposite case, that “There is not enough evidence yet to implement PrEP and make it widely available”, 41% agreed with this statement and 49% of those in the south.
When the reasons behind physicians’ opinions on PrEP were explored, they focused on risk compensation and side effects. Seventy-one per cent of physicians agreed strongly or moderately that PrEP “Could lead to the medicalisation of HIV prevention and shift focus from condom use and HIV campaigns,” with 42% strongly agreeing with this statement. A similar proportion thought PrEP might favour the spread of STIs, and 70% thought PrEP could be dangerous to individuals’ health if not used appropriately and safely, with 32% strongly agreeing.
Fifty-one per cent said that PrEP might not only be useful in gay men and other men who have sex with men (MSM) but also in heterosexual serodiscordant couples, but 36% thought PrEP was “mostly effective in MSM but not in other contexts.”
While 48% thought there was enough evidence to start prescribing PrEP and 56% thought health authorities had an ethical obligation to make PrEP available as part of strategies to prevent HIV (63% in teaching hospitals), only 42.5% thought that investing in PrEP would be an appropriate use of healthcare funding and 71% considered that funding PrEP through the Servizio Sanitario Nazionale (SSN), the Italian national healthcare system, would not be an economic use of resources.
Despite these attitudes, 52% said that they had considered prescribing PrEP for at least one patient and 63% had been asked about PrEP by at least one.
The authors of the study comment that at this time PrEP lacked an “innovative profile perception” among doctors, meaning that they were not convinced it would make a big enough difference to start providing it generally.
The survey reveals, if anything, more conservative attitudes towards PrEP than those revealed in a survey of 311 Italian HIV physicians published in 2013. In that survey 64% of respondents said they would prescribe PrEP were it available to people needing it.
Giulio Maria Corbelli, Chair of the European Community Advisory Board, commented: “This was the first investigation of this kind among clinicians and the sample size is not big enough; nonetheless, this shows how much is still to be done to improve HIV care in our country.
“This is underlined by the fact that during the months this survey was being conducted, Plus, the Italian association of people with HIV, launched a questionnaire about PrEP among gay men in Italy. People were much more positive about PrEP in that survey, especially those most at risk.”
However, Corbelli added that he did think that the perception of PrEP among clinicians had changed in the last couple of years, “Even though there is still a group of people moved by prejudice.”
On the doctors’ side, Professor Antonella d’Arminio Monforte, co-chair of the 2017 European AIDS Conference, which is happening in Milan next month, said: “In my opinion, a lot of progress has been made on the opinion of medical doctors on the usefulness of PrEP – and also among several advocacy groups who are now less reluctant than one year ago.”
This may be a generational phenomenon. PrEP opinion in Italian doctors shows a particularly strong relationship to their age. Although no similar survey of physician opinion has been conducted since, a qualitative survey that interviewed 24 healthcare workers in early 2017 was presented at the last Italian Conference on AIDS and Antiviral Research in June (Debbia). It found that the physicians who said that they had “no knowledge of PrEP”, who said they were against PrEP, or who thought PrEP was purely about seeking “sexual pleasure” were all aged over 45.
Di Biagio AD et al. PrEP in Italy: the time may be ripe but who’s paying the bill? A nationwide survey on physicians’ attitudes towards using antiretrovirals to prevent HIV infection. PLOS One 12(7):e0181433. Full text here. 2017.
Debbia F et al. PrEP as a preventative measure: what healthcare providers this about it. A qualitative research. ICAR (Italian Conference on AIDS and Antiviral Research), Siena. Poster #157. 2017.
