Recommendations for Increasing Physician Provision of Pre-Exposure Prophylaxis: Implications for Medical Student Training

Abstract

There is growing evidence that pre-exposure prophylaxis (PrEP) prevents HIV acquisition. However, in the United States, approximately only 4% of people who could benefit from PrEP are currently receiving it, and it is estimated only 1 in 5 physicians has ever prescribed PrEP. We conducted a scoping review to gain an understanding of physician-identified barriers to PrEP provision. Four overarching barriers presented in the literature: Purview Paradox, Patient Financial Constraints, Risk Compensation, and Concern for ART Resistance. Considering the physician-identified barriers, we make recommendations for how physicians and students may work to increase PrEP knowledge and competence along each stage of the PrEP cascade. We recommend adopting HIV risk assessment as a standard of care, improving physician ability to identify PrEP candidates, improving physician interest and ability in encouraging PrEP uptake, and increasing utilization of continuous care management to ensure retention and adherence to PrEP.

Pre-Exposure Prophylaxis Training among Medical Schools in the United States

“…To meet the goal of ending the HIV epidemic, PrEP content should be taught in all medical schools. 25 We found in our survey that only 38% taught PrEP content at all. Further, given the disproportionate burden of HIV experienced by MSM, bi-sexual, and transgender populations, content should include this population prominently, and in our sample even fewer schools, 15.4%, reported teaching this content.…”

“…A scoping review recently conducted by us identified lack of PrEP training in medical schools as one of the barriers to PrEP prescribing among physicians. 25 Lecture was reported as the most frequent method of teaching this content. Given our previous work on implicit bias, 26 it is clear that direct patient contact and simulations are needed to improve outcomes in work with LGBT patients.…”

“…A scoping review recently conducted by us identified lack of PrEP training in medical schools as one of the barriers to PrEP prescribing among physicians. 25…”

Response to a Reader’s Letter “Medical School Training Can Improve Patient Care”

“… 8 For example, CoP can be used to identify and develop primary care curriculum that introduces new teaching techniques. For instance, new models of training, including the use of audits and the patient-centered medical home, 9 - 11 are approaches that can be used to train medical students to prescribe PrEP 12 based on a patient’s risk and/or circumstance.…”

Improving HIV preexposure prophylaxis implementation within healthcare settings

“…PrEP guidelines, conferences, webinars, training modules, and public health detailing have improved HIV specialists’ and primary care providers’ knowledge of and willingness to prescribed PrEP [12,13]. Studies have shown that the number of HIV specialists and primary care providers who prescribe PrEP in the United States has risen steadily but remains insufficient [14,15]. Converting PrEP knowledge to discussion of PrEP with patients to prescription requires that providers discuss patients’ sexual practices, sexual health needs, and injection practices or other illicit drug use, conduct appropriate physical examinations and laboratory testing, navigate health insurance, and refer patients to other support services as needed [12,16].…”