Health Care Provider Barriers to HIV Pre-Exposure Prophylaxis in the United States: A Systematic Review

Abstract

Increasing prescription of pre-exposure prophylaxis (PrEP) is imperative to ending the HIV epidemic in the United States. The objective of this review was to identify health care provider barriers to PrEP implementation. A systematic review was conducted in February 2019 using PubMed to identify barriers to PrEP prescribing practices in the United States. Targeted search terms surrounding PrEP and providers resulted in 222 original studies, 28 of which were ultimately included in our review, with data collected between 2011 and 2018. Six themes were identified across reviewed studies: (i) a lack of PrEP knowledge, (ii) the presence of the Purview Paradox, which refers to discordance in beliefs between HIV specialists and primary care providers on who should prescribe PrEP, (iii) concerns about PrEP costs, (iv) concerns about behavioral and health consequences, (v) interpersonal stigma, and (vi) concerns about patient adherence. A majority of providers were lacking knowledge regarding PrEP, resulting in discomfort in prescribing PrEP, or limited awareness and understanding of PrEP clinical guidelines. Discrepant opinions were identified regarding whether PrEP was best managed within primary care or specialty clinics. Other barriers included concerns about cost, patient adherence, and follow-up maintenance care. Finally, concerns about risk compensation and discomfort discussing sexual activities with patients who would benefit most from PrEP were apparent. Additional work is needed to prepare providers to prescribe and manage patients on PrEP, optimize PrEP delivery, and reduce provider bias. Future research is needed to identify providers' attitudes and beliefs regarding innovations in PrEP dosing, task shifting, and novel strategies for PrEP care.

The current landscape of pre-exposure prophylaxis service delivery models for HIV prevention: a scoping review

“…Further research should therefore continue to focus on how to best engage, motivate and educate other health care workers, such as primary care physicians and lay providers. Insights in how to increase cooperation between different providers to integrate PrEP provision successfully into their practice, could present a way forward [18].…”

“…For this purpose, we defined a 'PrEP service delivery model' as consisting of four key components: the population targeted for PrEP, the infrastructural setting of PrEP provision, PrEP providers, and the applied delivery channels to make PrEP available. Existing literature reviews on earlier steps in the PrEP care continuum such as assessing eligibility and awareness about PrEP, and barriers and facilitators towards its uptake, do not fully respond to this need [17,18]. This review therefore focused on the delivery of services to people either initiating PrEP or continuing its use, and on understanding how these systems operate.…”

Knowledge needs for implementing HIV pre-exposure prophylaxis among primary care providers in a safety-net health system

“…For example, in an analysis of 2017 prescription data, the lowest PrEP-to-need ratio was seen in US South residents, and less than 10% of the estimated 1.2 million eligible individuals received PrEP ( Siegler et al, 2018 ). Several barriers to PrEP implementation have been identified among PCPs including stigma, lack of knowledge, and inadequate skills to prescribe PrEP ( Mayer et al, 2020 , Pleuhs et al, 2020 ). Nevertheless, limited evidence is available about potential barriers to PrEP implementation among PCPs in safety-net health systems, which may be particularly important in geographic regions where HIV incidence has increased ( CDC, 2019c , Singh et al, 2018 ).…”

The current landscape of pre-exposure prophylaxis service delivery models for HIV prevention: a scoping review

“…For this purpose, we de ned a 'PrEP service delivery model' as consisting of four key components: the population targeted for PrEP, the infrastructural setting of PrEP provision, PrEP providers, and the applied delivery channels to make PrEP available. Existing literature reviews on earlier steps in the PrEP care continuum such as assessing eligibility and awareness about PrEP, and barriers and facilitators towards its uptake, do not fully respond to this need [17,18]. This review therefore focused on the delivery of services to people either initiating PrEP or continuing its use, and on understanding how these systems operate.…”