The iPrEx and CAPRISA studies demonstrated that the use of antiretrovirals prior to exposure could help to reduce new HIV infections. Our study is the first to assess providers' knowledge, concerns, and willingness to provide PrEP following the release of the iPrEx trial data. Among this sample of Massachusetts area physicians, knowledge of topical and oral chemoprophylaxis was high—92% had heard of oral PrEP and 83% had heard about topical microbicides, post-iPrEx. Yet despite nearly 60% having previously prescribed some form of PEP, only 4% of the sample had prescribed PrEP post-iPrEx. Not surprisingly, HIV specialists had significantly more knowledge (p<0.01) and experience (p<0.001) providing antiretrovirals for prevention, compared to generalists, although PrEP provision remained limited among specialists (7% post-iPrEx). While Massachusetts physicians overwhelmingly indicated a preference for topical microbicides, primarily due to perceptions that gels would have fewer side effects than oral medication, those who preferred oral PrEP predominantly felt that it would be easier to take. These responses suggest a willingness to prescribe PrEP pending the availability of new efficacy data and further guidance from normative bodies.
As with any new treatment or intervention, uptake can be slow, and barred by both real and hypothetical concerns regarding the consequences of increased availability and delivery of the treatment. Community and scientific stakeholders have expressed ongoing concerns that widespread PrEP availability could lead to increases in sexual risk-taking among PrEP users (risk compensation).4–6,9,17,20
Providers in this study tended to express these concerns before the release of iPrEx clinical trial data, however, concerns decreased post-iPrEx. This suggests an awareness of the iPrEx results which did not find evidence of risk compensation among study participants.3
Instead, providers expressed increased funding concerns post-iPrEx (i.e., that the availability of PrEP would lead to decreases in available federal funds for other forms of HIV prevention and treatment). Nonetheless, providers indicated that they would support the provision of PrEP if modestly priced at $1.00 per use, with the majority of the post-iPrEx sample (73%) indicating that state health departments or public programs should pay for PrEP if patients cannot afford to pay for it themselves. This could present future challenges for implementing oral PrEP with tenofovir-emtirictabine, since the cost of this agent in the U.S. and other resource-rich nations is more than 100 times that price point.18,31–33
While concerns relating to PrEP's clinical efficacy declined post-iPrEx, providers noted that additional clinically efficacy data on at-risk persons could motivate them to prescribe PrEP, with providers on average supporting the provision of PrEP at an efficacy level of 71%. In fact, if proven highly effective, the majority of providers (95%) indicated that they would prescribe PrEP if it were a once daily pill. Given this result, an important consideration when educating providers will be to accurately convey the relationship between adherence and increasing partial efficacy that has been observed in several completed PrEP trials. For example, the overall efficacy of PrEP has ranged from 39% in CAPRISA 004 (with a topical formulation used pericoitally by African women) to 73% in the Partners PrEP study (with daily oral PrEP used by the HIV-uninfected members of serodiscordant heterosexual couples), but among subgroups of participants with excellent adherence in several studies, PrEP efficacy estimates have reached the 90% range.2,3,34,35
Additionally, fears relating to PrEP's potential unintended consequences could potentially act as a barrier to future PrEP provision as many providers expressed concerns about the development of antiretroviral resistance among PrEP users who become HIV-infected. Since efficacy is highly tied to medication adherence, it will be necessary to train providers in communicating concepts of adherence and partial efficacy, in addition to providing clinical monitoring—a time constraint more commonly cited by generalists than specialists.
Although the CDC released interim PrEP guidance in January 2011,36
the post-iPrEx sample indicated that further guidance from the CDC and other normative bodies could motivate them to prescribe PrEP. HIV specialists tended to place greater value on recommendations from specialty professional associations (e.g., IDSA, HIVMA etc.), while more generalists indicated that recommendations from the US Preventive Services Task Force could motivate them to prescribe PrEP in the future. Requests from patients were also cited as potential motivators for PrEP provision. Given recent data demonstrating a substantial interest in PrEP among at-risk MSM,37
it will be important for providers to make PrEP available to patients who could benefit from its use. However, research indicates that sexual risk taking histories are not routinely assessed in HIV or primary care settings due to provider time constraints, discomfort, lack of motivation and other barriers,11–15
making it potentially difficult for providers to identify appropriate candidates for PrEP use. Thus, future professional educational campaigns should not only aim to increase provider knowledge of PrEP and its appropriate provision, but also address provider barriers to allow for the integration of routine sexual risk inventories into medical care.
Some study limitations should be noted. First, our study used professional listserves and direct e-mail in recruiting providers to complete an anonymous, online survey before and after the release of iPrEx clinical trial data. Due to the anonymous nature of the survey, we were not able to track participant responses across surveys. Thus, unlike traditional repeat cross-sectional designs, it is likely that some of the individuals who completed the post-iPrEx survey, did not complete the pre-iPrEx survey, and vice versa. As a result of this limitation, the data of providers who completed both surveys may be biased toward greater knowledge and more amenable attitudes toward PrEP post-iPrEx. However, it is more plausible that the addition of new participants post-iPrEx served to skew the data in the other direction, as slight (not statistically significant) decreases were seen in microbicide knowledge post-iPrEx. Nonetheless, the demographic make-up of the two samples were similar with the exception of fewer HIV specialists, and thus fewer providers who had cared for specific subsets of HIV- infected persons in the post-iPrEx sample. Next, the recruitment lists were not exhaustive and may not have included all HIV specialists and generalists practicing in Massachusetts. Because of limited funding, this study was conducted with Massachusetts physicians only, and as such, our findings may not be fully generalizable to medical providers across the U.S. Finally, the results of this study are based on the PrEP-related knowledge, experience, and beliefs of Massachusetts physicians almost immediately post-iPrEx and may change over time as new information becomes available.
These findings warrant the development of educational programs aimed at incorporating antiretroviral chemoprophylaxis into physicians' HIV prevention practices. Such programs should take into account the range of professional education needs, addressing differences in PrEP awareness by provider specialty, concerns regarding the potential outcomes of PrEP, as well as the willingness and ability to effectively deliver PrEP and its associated package of comprehensive services.