Primary care clinicians’ experiences prescribing HIV pre‐exposure prophylaxis at a specialized community health centre in Boston: lessons from early adopters

Abstract

IntroductionAn estimated 1.2 million Americans have indications for using antiretroviral pre-exposure prophylaxis (PrEP) to prevent HIV acquisition. For many of these at-risk individuals, the best opportunity to learn about and receive PrEP will be during routine visits to their generalist primary care clinicians. However, few generalist clinicians have prescribed PrEP, primarily because of practical concerns about providing PrEP in primary care settings. The experiences of specialized primary care clinicians who have prescribed PrEP can inform the feasibility of PrEP provision by generalists.MethodsDuring January to February 2015, 35 primary care clinicians at a community health centre in Boston that specializes in the care of sexual and gender minorities completed anonymous surveys about their experiences and practices with PrEP provision. Responses were analyzed with descriptive statistics.Results and discussionThirty-two clinicians (response rate=91%) completed the surveys. Nearly all clinicians (97%) had prescribed PrEP (median 20 patients, interquartile range 11–33). Most clinicians reported testing and risk-reduction counselling practices concordant with U.S. Centers for Disease Control and Prevention guidelines for PrEP. Clinicians indicated that patients using PrEP experienced medication toxicities infrequently and generally reported high adherence. However, some clinicians’ practices differed from guideline recommendations, and some clinicians observed patients with increased risk behaviours. Most clinicians (79%) rated PrEP provision as easy to accomplish, and 97% considered themselves likely to prescribe PrEP in the future.ConclusionsIn a primary care clinic with specialized expertise in HIV prevention, clinicians perceived that PrEP provision to large numbers of patients was safe, feasible and potentially effective. Efforts to engage generalist primary care clinicians in PrEP provision could facilitate scale-up of this efficacious intervention.

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

“…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.…”

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

“…Another theme we identified in the literature was the belief that being on PrEP would cause individuals to engage in more ''risky'' behavior, such as having sex without a condom or not inquiring about STIs before engaging in sexual activity. 25,[27][28][29]33,34,36,37,39,42,43,45,49,50 Although in most studies worries about risk compensation were minimal, it did emerge as a common theme across the reviewed literature. Specifically, 26% of Washington State providers believed that being on PrEP could increase engagement in risky sexual behavior.…”

“…49 Moreover, some providers had misgivings about prescribing PrEP, stating that they thought it would lead to an increase in risky behavior and increased HIV transmission, with some providers stating that patients had disclosed increased risky behavior after starting PrEP. 36,37 Some providers even stated that higher-risk individuals would be better off using condoms instead of PrEP. 33 Another study found that fears of risk compensation were more prominent in providers with little PrEP prescribing experience.…”

Pre-exposure prophylaxis for MSM and transgender persons in early adopting countries

“…infectious diseases specialists [91], primary care clinicians [121], and STI clinicians [46]) might encourage a greater number of providers to consider PrEP as part of their clinical purview.…”