Differing Experiences with Pre-Exposure Prophylaxis in Boston Among Lesbian, Gay, Bisexual, and Transgender Specialists and Generalists in Primary Care: Implications for Scale-Up

Abstract

The Centers for Disease Control and Prevention estimates that one in four sexually active men who have sex with men (MSM) could decrease their HIV risk by using HIV pre-exposure prophylaxis (PrEP). Because many MSM access healthcare from primary care providers (PCPs), these clinicians could play an important role in providing access to PrEP. Semistructured qualitative interviews were conducted with 31 PCPs in Boston, MA, to explore how they approach decisions about prescribing PrEP to MSM and their experiences with PrEP provision. Purposive sampling included 12 PCPs from an urban community health center specializing in the care of lesbian, gay, bisexual, and transgender persons ("LGBT specialists") and 19 PCPs from a general academic medical center ("generalists"). Analyses utilized an inductive approach to identify emergent themes. Both groups of PCPs approached prescribing decisions about PrEP as a process of informed decision-making with patients. Providers would defer to patients' preferences if they were unsure about the appropriateness of PrEP. LGBT specialists and generalists were at vastly different stages of adopting PrEP into practice. For LGBT specialists, PrEP was a disruptive innovation that rapidly became normative in practice. Generalists had limited experience with PrEP; however, they desired succinct decision-support tools to help them achieve proficiency, because they considered preventive medicine to be central to their professional role. As generalists vastly outnumber LGBT specialists in the United States, interventions to support PrEP provision by generalists could accelerate the scale-up of PrEP for MSM nationally, which could in turn decrease HIV incidence for this priority population.

Access to HIV Pre-exposure Prophylaxis in Practice Settings: a Qualitative Study of Sexual and Gender Minority Adults’ Perspectives

“…Providers have endorsed the suggestion of increased PrEP training. 47 PCPs should also be encouraged to initiate conversations with their patients about PrEP, as our research agrees with previous studies showing that patients bear the burden of introducing this topic. 47,57 Crucial next steps include developing and testing interventions to improve patient-provider relationships, especially around sexual health.…”

“…However, many PCPs lack the knowledge to be comfortable and effective in prescribing and managing PrEP, including providing followup care, as observed in our study and previous research. 47,[51][52][53] Several participants in this study accessed PrEP through community-based sexual health clinics, and all described positive experiences. Fewer reports have examined the provision of PrEP in this context.…”

“…There is on-going discussion about the role of different types of providers in prescribing PrEP, particularly PCPs and infectious disease specialists. [43][44][45][46][47] PCPs are a preferred source of PrEP for many patients, 48,49 and increased trust in a PCP is associated with increased PrEP willingness. 50 This corroborates our finding that many participants felt more comfortable discussing sensitive topics with a provider they already knew and trusted.…”

Implementation of HIV Preexposure Prophylaxis in a Homeless Primary Care Setting at the Veterans Affairs

“…Similar findings have been seen in multiple settings in other studies as well. [22][23][24] Our PrEP interventions received significant support from nonprescribing clinic staff and trainees. The inclusion of multiple health care professions and ancillary support staff in this process is unique, but important to ensure widespread impact and ongoing success of PrEP in the homeless primary care setting.…”

HIV pre-exposure prophylaxis: Knowledge and attitudes among general practitioners

“…Other studies have indicated that formalised guidelines on PrEP prescription from a recognised institution would influence GP prescribing. 6,9,10,22,23 The ASHM has since released a range of education options for PrEP providers including full guidelines, webinars, online learning modules and a two-page decision-making tool. 21 It is important that education continues to be offered in a variety of modalities to reach all providers.…”