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


Our survey of HIV providers' knowledge and attitudes about PrEP and willingness to provide it in 2 high HIV prevalence cities found that most (53%) agreed that PrEP is an effective HIV prevention approach. However, a small percentage of providers (17%) reported ever prescribing PrEP. In 1 national survey conducted in June 2013, several months after this survey and after the release of the updated CDC guidelines, 74% of infectious disease specialists supported PrEP as a prevention strategy, but only 9% reported actually prescribing PrEP.[31] Though our study found twice this rate of prescribing (17%) even before this national study and the final CDC guidelines, this is still quite a low rate of prescribing.

We identified 2 distinct groups of providers: one found PrEP to be moderately effective, and perceived fewer barriers to prescribing PrEP than did the other group, in which participants considered PrEP to be less effective. Interestingly, no significant differences were found between the 2 classes of providers in their demographic characteristics or field of, size of, or years in practice. However, there were significant differences between them regarding their knowledge about and familiarity with PrEP. For example, the providers finding PrEP to be moderately effective with fewer prescribing barriers were more likely to have received requests for PrEP or have ever prescribed it. Thus, those with more experience with PrEP perceived fewer barriers.

Perceptions regarding practice-related barriers also set the 2 provider groups apart. Class 1, the group that found PrEP to be less effective and with barriers, was more likely to agree with statements regarding practice-related barriers. Previously conducted studies have documented that practice-related perceived barriers to PrEP provision are common among providers caring for HIV-infected or high-risk persons. For example, providers in a California-based survey frequently expressed belief that their clinics' current care models were insufficient to adequately support PrEP provision.[9] Other studies have also found that one of the most common perceived barriers to PrEP provision among infectious disease physicians was its time-consuming nature.[31] In our study, nearly all providers in class 2 expressed high levels of agreement with statements related to the feasibility of PrEP delivery and the time required for it as compared with only half of class 1, but class 1 participants generally had less experience with PrEP than those in class 2, and were more likely to work for medical practices without written PrEP protocols. Although class 1 providers expressed sentiments that providing PrEP could be burdensome, there are no studies that we are aware of that have systematically assessed provider experiences during the provision of PrEP. These findings highlight the need for education about PrEP and assistance in implementing structural or procedural changes needed in clinics to facilitate efficient and effective PrEP delivery. Such interventions may prevent potential misconceptions of providers with little PrEP experience about the ability to provide this service.

Another important difference between the provider groups was that those who found PrEP moderately effective and perceived fewer barriers had comparatively more knowledge about and experience with PrEP, and were more likely to prescribe it to persons with multiple sex partners and noninjection drug users. As noninjection drug use is neither a direct risk factor for HIV nor a current risk behavior meeting the criteria for PrEP use, future studies should examine whether providers are more likely to prescribe to noninjection drug users whose partners are HIV positive or who have multiple sex partners, for example. These findings suggest physicians may exhibit the same reluctance to prescribe PrEP to drug users as they did with prescription of ART to drug users early in the HIV epidemic.[32,33] Despite the fact that the current CDC PrEP guidelines do not recommend prescribing solely based on noninjection drug use, there is sufficient evidence to suggest that this may be a factor for consideration in assessing one's high-risk behaviors and the need for PrEP. Both groups, however, had clear concerns about prescribing PrEP to individuals with characteristics indicative of nonadherence;[15] less than 5% of providers were likely to prescribe PrEP to patients who miss medical appointments or who have been nonadherent with other medications. Ensuring high rates of adherence with PrEP use is essential to maximizing its efficacy,[5] and providers' responses may reflect this concern.

Both groups of providers also identified potential barriers to PrEP use related to the risk for drug resistance and risk compensation that were consistent with findings from other studies of potential physician providers of PrEP. A 2013 study of US infectious disease physicians found that, while most (74%) supported PrEP provision, 77% of those who expressed reluctance were worried about adherence and the potential for future drug resistance. Furthermore, 53% were concerned about the cost of the drug and reimbursement procedures.[31] Similarly, a 2013 survey of HIV health care providers in the United States found that drug resistance, risk compensation, and adherence were respondents' top 3 concerns; drug cost was the fourth most common concern.[15] Potential providers of PrEP ought to be familiar with the results of the sentinel PrEP efficacy studies and their follow-on open label studies. These studies have found very low rates of transmitted resistance and no increase in risky behavior among PrEP users.[1,2,4,34,35] However, as real-world implementation and scale-up begin, continued monitoring of these issues will be essential.

This study has some potential limitations. This study used a convenience sample and we are unable to compare the characteristics of respondents to those who did not respond. However, based on the practice characteristics provided, the participants in this study represent experienced HIV providers in 2 major urban areas. It does not reflect the perspectives of providers not treating HIV-positive patients and therefore may not be generalizable to the broader provider population who may turn out to be the primary PrEP prescribers.[36–38] Furthermore, it only includes providers in areas of high HIV prevalence and thus may not represent the perceptions and intentions of providers in lower HIV prevalence areas. Primary care provider perspectives may vary with respect to familiarity, concerns, and experience with PrEP and HIV prevention. Given the limited number of HIV providers, primary care providers' participation in PrEP provision will be necessary to maximize scale-up of PrEP. Therefore, future studies should elicit the perspectives and prescribing experiences of non-HIV primary care providers.

As PrEP becomes more widely available and its use potentially increases, providers will need to learn about PrEP and determine how best to deliver it in their practices. Notably, when our survey was administered efficacy results were only available from the iPrEX study,[1] and soon thereafter the US FDA approved Truvada for the use of PrEP. Additionally, the surveys were administered before release of both the CDC interim[23,39,40] and final guidelines[5] on PrEP as well as the release of findings from key studies of PrEP efficacy among heterosexuals[2,42,4] and injection drug users.[3] As the official guidelines are now available, provider familiarity with PrEP and overall uptake will likely increase and a follow-up survey of providers would be warranted given the evolution of our knowledge of PrEP since this survey was initially administered.[12,13,17,18] Although provider knowledge of PrEP increased following the release of the iPrEx trial results,[13] as of 2013, as many as 25% of providers in some settings were still unaware of the FDA approval or CDC guidance.[41] It is therefore important to monitor future changes in provider knowledge, attitudes, and practice.[5] Providing technical support to facilitate implementation of clinical guidelines and resources for billing and insurance coverage will help providers make PrEP accessible.

PrEP should be considered a tool in the armament for HIV prevention. Providers must be comfortable with and have the tools to identify persons at high risk for HIV infection and be prepared to assist them with determining the most appropriate HIV prevention method for them while taking into consideration their lifestyle and risk profile. In anticipation of patient requests for PrEP, providers must have protocols to properly identify and monitor PrEP users. They must also be comfortable identifying persons who are not PrEP candidates but may benefit from other HIV prevention methods, including behavior modification and condom use.[13] Finally, monitoring and evaluating PrEP implementation and provider attitudes over time is essential to addressing barriers to uptake, so that PrEP is accessible to patients who may benefit from it.