Seventy per cent of Italian HIV specialists who answered an online survey would prescribe pre-exposure prophylaxis (PrEP) to people in their care who ask for it, at least in some circumstances, a study has found.
The survey uncovered considerable training needs around PrEP. Most specialists described their knowledge of PrEP as “not detailed”. Most said they wanted a multi-centre effectiveness trial and national guidelines on PrEP in Italy.
Despite the majority indicating willingness to prescribe PrEP, most specialists were concerned about its efficacy, potential toxicity, impact on behaviour and cost and the vast majority believed that improved testing and treatment for people with HIV was a more effective preventive measure than PrEP.
The 30% who said they would not prescribe PrEP under any circumstances were particularly concerned about side-effects, and over half were worried that PrEP could be used by people as a false reassurance, as a substitute for testing for HIV. They were also considerably more likely to believe that behavioural interventions such as safer-sex counselling were more effective in preventing HIV than PrEP – although this belief was widely shared amongst those who would prescribe PrEP too.
The survey was conducted between February and May 2012, at a time when the results from the iPrEx, CAPRISA 004, Partners PrEP and TDF2 trials had been published or presented and where the negative result of the FEM-PrEP study was known. The survey was initially developed by a focus group of ten HIV specialists and took some of its questions from a previous survey of physicians' attitudes towards PrEP conducted by the Fenway Institute in Boston, USA. The study was then put online and physicians were notified via an email listserv for HIV specialists.
Who would prescribe PrEP – and who to
In all, 311 doctors answered the survey, representing about 40% of Italian HIV specialists. The majority were male and over 50 years old and had been working with people with HIV for over 20 years.
Of these, 95 (30.5%) said that they would not prescribe PrEP under any circumstances and were classed as having a 'negative' attitude to PrEP.
Of the majority who were classed as 'positive' about PrEP, 93% (64% of all physicians) said they would prescribe PrEP, when requested, to the HIV-negative partner in an HIV-serodiscordant relationship; 81% to people at high ongoing risk of HIV (56% of all physicians); 70% to gay men in general; 61% to sex workers; and 58% to people presenting with acute sexually transmitted infections. In contrast, only 21% (14% of the whole group) said they would prescribe PrEP to injecting drug users.
The majority said they would only prescribe PrEP to people not using condoms, but a substantial minority (15 to 20% of the whole group) said they would prescribe PrEP even to people who said they did use condoms if it was requested.
Physicians who said they would prescribe PrEP under some circumstances were asked specifically under what circumstances they would prescribe PrEP to the HIV-negative partner in a serodiscordant couple. Approximately 80% said they would prescribe it to a female or to a gay male partner, 70% for a male heterosexual partner or to a woman wanting PrEP because she wished to conceive, and 60% to the male partner of a woman with HIV who wished to conceive. Interestingly, about one-third of these physicians said they would prescribe PrEP if requested even if the HIV-positive partner had an undetectable viral load.
Physicians were asked what they would do if consulted by a serodiscordant couple where the partner with HIV had a CD4 count above the threshold for starting treatment. Fifty-five per cent said they would just recommend safer sex, 27% said they would prescribe antiretroviral (ARV) therapy for the positive partner, 9% said they would prescribe PrEP to the negative partner, and 10% would prescribe ARVs to both. Those with positive attitudes to PrEP were nearly five times as likely as those with negative attitudes to say they would start the HIV-positive partner on ARVs regardless of treatment guidelines.
Few characteristics were associated with physicians' willingness to prescribe PrEP. The 82% of doctors who had ever prescribed post-exposure prophylaxis (PEP) to anyone were 2.5 times more likely to have a positive attitude to PrEP, as had the 65% who had received specific training on PEP. There was a tendency for those with better self-rated knowledge about PrEP to have more positive attitudes, but this was not statistically significant.
Concerns about PrEP
Despite the majority being willing to prescribe PrEP, most respondents were very wary of it. Eighty per cent (of all respondents) said they were concerned PrEP might not be effective, 80% that it was too costly, 73% that it might lead to riskier behaviour, 70% that it might have long-term toxicity and 69% that it could lead to drug resistance; 62% were concerned about poor adherence. A vast majority (91%) thought that testing and treating people with HIV would be more effective as a prevention measure than PrEP and a similarly large proportion that behavioural interventions were safer. Three-quarters of all respondents thought that behavioural interventions would also be more effective than PrEP.
Several factors were of particular concern to the 30% who said they would never prescribe PrEP. These physicians were more than twice as likely as others to be concerned about side-effects and nearly four times as likely to believe that behavioural interventions would be more effective. A majority of them were also worried that PrEP might be used as a 'false reassurance' substitute for HIV testing.
Guidelines, trials and payment
Eighty per cent of respondents said they would prefer to prescribe PrEP with backing from formal guidelines and 60% said they would prefer to prescribe it after a multi-centre effectiveness trial had been done.
In terms of who should pay for PrEP, a third said the patient should pay for it. Of the other two-thirds, 43% each said the national health service should pay the whole cost or that the patient should partly pay for it; the remainder said that it should be free in some circumstances such as conception. Few respondents with negative attitudes to PrEP were happy about the health service paying for it.
As the researchers point out, these attitudes are roughly in line with those expressed in a survey conducted at the 2012 IAPAC evidence summit on treatment as prevention and PrEP, where 91% of attendees said they would like formal PrEP guidelines and 56% cited cost as the biggest barrier to PrEP implementation.
In conclusion, the majority of Italian HIV specialists would be prepared to prescribe PrEP. The 70% in favour is a more pro-PrEP result than a poll published in the New England Journal of Medicine in 2012, which found a 50/50 split in its readers for and against PrEP prescription. However, as the authors of the paper say, “Conflicting attitudes appear evident, and reflect uncertainties within the medical and public health communities over which approaches will most effectively control the global spread of HIV.”
They add: ”Identifying the populations most at risk of HIV infection and for whom PrEP would be most effective, and linking them to and retaining them in care, is one of the emerging challenges.”
Puro V et al. Attitude towards antiretroviral pre-exposure prophylaxis (PrEP) among HIV specialists. BMC Infectious Diseases 13:217, 2013. The full text of this paper is available here.