Evidence of Potential Discriminatory HIV Pre-Exposure Prophylaxis (PrEP) Prescribing Practices for People Who Inject Drugs Among a Small Percentage of Providers in the U.S.

Abstract

Introduction: A large percentage of people who inject drugs (PWID) are living with HIV. Yet, rates of HIV pre-exposure prophylaxis (PrEP) use among PWID remain low. Stigma surrounding substance use and PWID have been identified as potential barriers to PrEP. This study examined healthcare providers’ concerns regarding PWID and willingness to prescribe PrEP to PWID. Methods: An online, cross-sectional survey of a diverse group of healthcare providers in the 10 U.S. cities with the greatest HIV prevalence was conducted between July 2014 and May 2015. Participants responded to a patient vignette of a PWID and asked to indicate whether the patient would be a candidate for PrEP and why via free-response text. Descriptive statistics are reported using frequency measures. Bivariate analyses were conducted using chi-squared comparisons and logistical regression. Results: Survey data from 480 providers were included in analyses. Of the 480 responses, 85.5% were classified as PrEP aware, while 14.2% were PrEP unaware. Additionally, 82.6% indicated the patient would be a good candidate for PrEP, 4.4% believed the patient was not a good candidate for PrEP, and 13% were unsure. Among those who were unsure or would not prescribe PrEP (n = 84), open-ended responses indicated lack of knowledge (42.9%), concern about adherence (27.4%), concern about cost (4.8%), and bias (7.1%) as the primary reasons. Conclusions: Although the majority of providers in this study did not demonstrate bias against PWID, our study found that limited PrEP knowledge and bias are barriers to PrEP prescription among PWID for some providers. Interventions are needed that increase PrEP awareness of CDC guidelines and reduce implicit bias among providers.

A Capacity-Strengthening Intervention to Support HIV Pre-exposure Prophylaxis (PrEP) Awareness-Building and Promotion by Frontline Harm Reduction Workers in Baltimore, Maryland: A Mixed Methods Evaluation

“…However, in the U.S., PrEP remains under-prescribed to and under-utilized by PWID, who may benefit from PrEP in the context of receptive syringe sharing and/or high-risk sexual behavior [ 3 ]. Among healthcare providers, limited PrEP knowledge, discomfort prescribing PrEP, and stigmatizing attitudes towards drug use constrain PrEP accessibility for PWID [ 4 – 6 ]. Likewise, low PrEP awareness stymies PrEP interest, willingness, and uptake among PWID [ 7 – 10 ].…”

Awareness, knowledge, and attitudes related to HIV pre-exposure prophylaxis and other prevention strategies among physicians from Brazil and Mexico: cross-sectional web-based survey

“…Low knowledge about PrEP, lack of time, cost, antiretroviral resistance, the purview paradox (the belief that PrEP prescription is beyond one's clinical domain), interpersonal stigma, anticipated risk compensation, and PrEP adherence were the main reported concerns of health care physicians in the USA [20][21][22][23]. Low willingness to prescribe PrEP has been associated with providers' racial bias or prejudice about key populations behavior, especially in their PrEP adherence capacity [24,25]. Studies in LAC reveal variations in awareness and willingness to prescribe PrEP among general practitioners or physicians with a medical specialty.…”