Putting PrEP into Practice: Lessons Learned from Early-Adopting U.S. Providers’ Firsthand Experiences Providing HIV Pre-Exposure Prophylaxis and Associated Care

Abstract

Optimizing access to HIV pre-exposure prophylaxis (PrEP), an evidence-based HIV prevention resource, requires expanding healthcare providers’ adoption of PrEP into clinical practice. This qualitative study explored PrEP providers’ firsthand experiences relative to six commonly-cited barriers to prescription—financial coverage, implementation logistics, eligibility determination, adherence concerns, side effects, and anticipated behavior change (risk compensation)—as well as their recommendations for training PrEP-inexperienced providers. U.S.-based PrEP providers were recruited via direct outreach and referral from colleagues and other participants (2014–2015). One-on-one interviews were conducted in person or by phone, transcribed, and analyzed. The sample (n = 18) primarily practiced in the Northeastern (67%) or Southern (22%) U.S. Nearly all (94%) were medical doctors (MDs), most of whom self-identified as infectious disease specialists. Prior experience prescribing PrEP ranged from 2 to 325 patients. Overall, providers reported favorable experiences with PrEP implementation and indicated that commonly anticipated problems were minimal or manageable. PrEP was covered via insurance or other programs for most patients; however, pre-authorization requirements, laboratory/service provision costs, and high deductibles sometimes presented challenges. Various models of PrEP care and coordination with other providers were utilized, with several providers highlighting the value of clinical staff support. Eligibility was determined through joint decision-making with patients; CDC guidelines were commonly referenced but not considered absolute. Patient adherence was variable, with particularly strong adherence noted among patients who had actively sought PrEP (self-referred). Providers observed minimal adverse effects or increases in risk behavior. However, they identified several barriers with respect to accessing and engaging PrEP candidates. Providers offered a wide range of suggestions regarding content, strategy, and logistics surrounding PrEP training, highlighting sexual history-taking and sexual minority competence as areas to prioritize. These insights from early-adopting PrEP providers may facilitate adoption of PrEP into clinical practice by PrEP-inexperienced providers, thereby improving access for individuals at risk for HIV.

PrEP Awareness, Familiarity, Comfort, and Prescribing Experience among US Primary Care Providers and HIV Specialists

“…This also suggests that the anticipated burden of barriers to prescribing PrEP is greater than what providers experience once they actually prescribe it. Thus, interventions promoting PrEP among providers may be more successful by addressing each barrier specifically and perhaps by presenting data from this and other studies [33] suggesting that the burden of these barriers is lower among providers who actually prescribe PrEP. The most prevalent concern or negative attitude toward PrEP was the thought that patients should use condoms instead of PrEP, an idea endorsed by about one-third of the sample.…”

Global implementation of PrEP for HIV prevention: setting expectations for impact

“…In theory, the target for PrEP persistence is simple: individuals should take PrEP as long as they are at risk for HIV, a PrEP IMPACT concept known as prevention-effective adherence [36]. However, this concept can be challenging to put in practice for individuals (as mapping risk may be difficult for both PrEP users and providers) and for programmes (since measuring use and risk periods may be difficult to measure and track at scale); financial and systematic barriers may also impede patients from achieving their desired persistence [42][43][44]. For individuals, risk should be considered in terms of periods or seasons, not days or weeks [45]; thus, we suggest an expectation of six months of use, while not a perfect fit for all PrEP users, might be useful for programme evaluation and good habit development [46].…”

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

“…Some providers have applied this score in their clinical practice [51], but use of this and other risk assessment tools is not widespread. Other international guidelines do not utilize a risk score, but provide criteria to identify which MSM and transgender women are at greatest risk [52, 53].…”

“…A qualitative study with Black MSM in New York City to assess barriers to utilizing PrEP found that participants felt mistrustful of and disempowered by health care providers when discussing sexual health histories and HIV prevention options, and that a recommendation to use PrEP would not be sufficiently compelling for them to initiate PrEP [124]. These results indicate a need to train providers in how to conduct patient-centered, nonjudgmental sexual health histories and discussions about PrEP, which would ideally include elements of rigorously tested, culturally-tailored prevention messages about PrEP for disenfranchised populations [51] and clear communication of acceptance towards LGBT individuals.…”