Understanding HIV Care Provider Attitudes Regarding Intentions to Prescribe PrEP

Amanda D. Castel, MD, MPH; Daniel J. Feaster, PhD; Wenze Tang, MPH; Sarah Willis, MPH; Heather Jordan, MPH; Kira Villamizar, MPH; Michael Kharfen, BA; Michael A. Kolber, MD, PhD; Allan Rodriguez, MD; Lisa R. Metsch, PhD


J Acquir Immune Defic Syndr. 2015;70(5):520-528. 

In This Article

Abstract and Introduction


Introduction: Preexposure prophylaxis (PrEP) is a promising approach to reducing HIV incidence. So, garnering the support of HIV providers, who are most familiar with antiretrovirals and likely to encounter patients in HIV serodiscordant relationships, to scale-up PrEP implementation is essential. We sought to determine whether certain subgroups of HIV providers were more likely to intend to prescribe PrEP.

Methods: Surveys were administered to HIV providers in Miami, Florida and Washington, District of Columbia. Composite scores were developed to measure PrEP knowledge, experience, and likelihood of prescribing. Latent class analysis was used to stratify provider attitudes toward PrEP.

Results: Among 142 HIV providers, 73.2% had cared for more than 20 HIV-infected patients in the previous 3 months; 17% had ever prescribed PrEP. Latent class analysis identified 2 classes of providers (entropy, 0.904); class 1 (n = 95) found PrEP less effective and perceived barriers to prescribing it; class 2 (n = 47) perceived PrEP as moderately effective and perceived fewer barriers to prescribing it. Compared with class 2, class 1 had significantly less experience with PrEP delivery (t(22.7) = 2.88, P = 0.009) and was significantly less likely to intend to prescribe to patients with multiple sex partners (20% vs. 43%, P = 0.04) and those with a drug use history (7% vs. 24%, P = 0.001).

Conclusions: Although most HIV providers found PrEP to be effective, those considering it less effective had limited knowledge and experience with PrEP and had lesser intentions to prescribe. Provider training regarding whom should receive PrEP and addressing potential barriers to PrEP provision are needed if this HIV prevention method is to be optimized.


Given high rates of HIV infection worldwide, biomedical prevention interventions have recently become a cornerstone of HIV prevention efforts. Preexposure prophylaxis (PrEP), a biomedical intervention, has proven effective among key high-risk populations, including men who have sex with men, high-risk heterosexuals, and injection drug users.[1–4] In clinical trials, daily oral PrEP using emtricitbine + tenofovir disoproxil fumarate (Truvada, Gilead Sciences, Foster City, CA) has been between 74% and 92% effective in reducing one's HIV risk, depending on the population studied and measures of detectable drug levels.[5]

PrEP is a promising approach to reducing HIV incidence. Its real-world use, which has been limited,[6] may be due to several factors. First, potential PrEP users must know about it, understand its risks and benefits, and be willing to take it.[7] Studies have shown that certain high-risk populations have limited knowledge of PrEP but want to learn more about it.[8] Furthermore, appropriate PrEP administration is available by prescription only and requires specialized counseling, regular HIV testing, close clinical monitoring for side effects, and follow-up beyond routine clinical care.[5] These tasks require a significant commitment from both patients and providers and may make both groups apprehensive about using PrEP. Using PrEP without consistent clinical monitoring or patient adherence may increase the risk of side effects such as renal toxicity and future drug resistance.[5]

HIV providers will be essential in the scale-up and delivery of PrEP as they are most familiar with antiretrovirals (ARVs) and may therefore be frontline providers of PrEP. Previous studies in the United States and abroad have assessed HIV providers' knowledge and perceptions of PrEP and perceived barriers to PrEP uptake.[9–17] Commonly cited issues have included: (1) comfort with prescribing ARVs for prevention and debate over whether this role is better suited for HIV specialists or primary care providers;[16] (2) ability and willingness to identify potential PrEP users by evaluating patients' HIV risk;[18] (3) levels of real-world PrEP effectiveness and adherence balanced with the potential for risk compensation and drug resistance;[10,13,16] (4) costs related to medications and the availability of insurance coverage;[8,10,13,14] and (5) ethical allocation of ARVs.[8,13]

Findings from studies of providers highlight the complexities of scaling-up and delivering PrEP in real-world settings.[8,9,19] Although general knowledge about and support for PrEP have increased since the Food and Drug Administration (FDA) approved Truvada and the Centers for Disease Control and Prevention (CDC) released the prescribing guidelines, knowledge of PrEP among providers has increased only slightly,[13] and actual prescribing rates remain relatively low.[6] Understanding providers' perceptions of PrEP and gauging their willingness to provide it will help to inform the implementation process and to make PrEP a more useful tool against HIV.

In Miami, Florida and Washington, District of Columbia, 2 US cities with high HIV prevalence rates,[20] PrEP availability may help to significantly reduce HIV incidence. The CDC funded both cities through the Enhanced Comprehensive HIV Prevention Planning Initiative (ECHPP) to maximize uptake of high-impact HIV prevention methods.[21] The ECHPP initiative predated the release of many of the sentinel PrEP studies, and therefore did not include an initiative on PrEP, but did include "provision of Post-Exposure Prophylaxis (PEP) to populations at greatest risk." The District of Columbia and Miami-Dade Departments of Health collaborated with District of Columbia and University of Miami Center for AIDS Research to assist with implementation of this initiative. While assessing the potential scale-up of PEP,[22] the District of Columbia and Miami Center for AIDS Research ECHPP teams also conducted a provider assessment evaluating the potential for PrEP uptake. Our objective was to use latent class analysis (LCA) techniques to identify subgroups of providers, based on their attitudes toward prescribing PrEP, to characterize which types of providers perceive fewer barriers to PrEP implementation and may therefore be more likely to intend to prescribe PrEP.