Pre-exposure prophylaxis (PrEP) was a hot topic at this year's annual IDWeek conference in San Diego, Calif. Among the many PrEP studies presented at the conference, several reflected one recurring takeaway: Clinicians and medical students need better education regarding not only how PrEP works and whom it can benefit but also that it even exists as an HIV prevention option.
Experts say this new research implies that if all health care providers -- not just infectious disease (ID) clinicians -- felt comfortable talking with patients about PrEP, then uptake of the HIV prevention pill would improve among some high-risk individuals who are good candidates for PrEP but have never been offered a prescription.
"We know that large disparities exist in PrEP access," said Brandon Imp, M.D., internal medicine/preventive medicine resident at Kaiser Permanente San Francisco and lead author of one of the PrEP studies presented at IDWeek. "Improving medical education and provider awareness of PrEP will be needed to reach all populations who may be at risk for HIV infection."
Official Centers for Disease Control and Prevention guidelines recommend PrEP for individuals who are at "substantial risk" for HIV, a broad term that encompasses having an HIV-positive sexual partner, multiple sexual partners, a recent sexually transmitted infection diagnosis, a history of inconsistent or no condom use and a likelihood of sharing injection drug equipment. Some experts suggest that even those guidelines are not broad enough.
Yet, at IDWeek, several abstracts indicated limited awareness of PrEP among health care professionals, from medical students to emergency department clinicians to primary care physicians. In addition, some abstracts highlighted that, even when providers were aware of PrEP, they often felt uncomfortable or were unwilling to talk with their patients about it.
For example, in one survey of 80 providers at Tufts Medical Center -- including physicians, nurses, physician assistants and medical students -- 32.5% had never heard of PrEP. Of those who had heard of PrEP, their knowledge was limited. Only about half knew that it should be taken every day, while about two-thirds correctly identified the standard PrEP regimen as tenofovir/emtricitabine (Truvada).
Many of the providers who knew about PrEP were uncomfortable prescribing it because they felt they did not know enough about it (72.5%), did not have enough experience with it (56.3%) or worried it would not be covered by a patient's insurance (17.5%).
Only 15.3% of providers qualified to prescribe PrEP had done so prior to the survey.
"There are some important gaps in knowledge about, and prescribing practice of PrEP, for HIV in some medical providers," said Rapeephan R. Maude, M.D., the primary author of the Tufts study.
"Medical providers should be trained to be comfortable to ask about risks for acquiring HIV, such as sexual history or history of intravenous drug use," Maude said. "Also, medical providers should have sufficient knowledge about PrEP to advise patients."
According to another IDWeek abstract more narrowly focused on primary care providers (PCPs), about half of over 300 surveyed PCPs and mid-level care providers at Baystate Medical Center in Springfield, Mass., had discussed PrEP with their patients who are men who have sex with men (MSM). In addition, only 19% of PCPs reported that they "always" asked MSM patients about their sexual practices.
Meanwhile, at an emergency department in St. Louis, Mo., 79% of physicians surveyed said they had heard of PrEP, yet only 43% felt comfortable discussing it with patients. They also had some misconceptions about PrEP, with 54% expressing concern that PrEP is not effective.
Interestingly, nearly all the physicians reported being very comfortable talking with patients about other related topics, such as intravenous drug use (100%) and sexual practices (96%). In addition, 94% reported a desire to learn more about PrEP.
"Most emergency room physicians were aware of PrEP, but there were concerns about efficacy," said Brett Tortelli, B.A., lead author of the study and an M.D./Ph.D. student at Washington University, speaking at a press conference. "These findings suggest future provider training should focus on misinformation."
Emergency rooms and primary care practices are two places where patients who are at high risk of HIV might seek care, experts explained.
"PCPs were not sure [about PrEP]. They were referring patients to ID doctors or asking them to come back, so that delays initiation of PrEP," said Maude.
"The emergency department also offers an opportunity to identify HIV-negative individuals at high risk for becoming infected in the future," Tortelli added.
According to Maude, who led the Tufts research, "If the medical providers had better knowledge about, attitudes to and practice of PrEP for HIV infection and were more comfortable to advise and prescribe PrEP, the coverage of PrEP should improve significantly in high-risk groups."
"Providers should be more comfortable asking their patients about risk factors," agreed Rajesh Gandhi, M.D., director of HIV clinical services and education at Massachusetts General Hospital and one of the HIV Medicine Association representatives on the IDWeek program committee.
Creating that comfort can begin while future clinicians are still in medical training. "Prior studies have recommended teaching physicians about PrEP as early as medical school," Imp said. Yet, when Imp and his colleagues surveyed PrEP awareness among 1,588 medical students across the country, they found that 28% were not aware of PrEP and 18% of graduating fourth year students were never taught about PrEP.
In addition, 57% responded that behavioral interventions should be tried first, 45% said patients were unlikely to adhere to PrEP and 22% expressed concern that PrEP is not effective.
"The next generation of physicians are being inadequately taught -- and, in some instances, not taught at all -- about PrEP in medical school," Imp said. "In order to close the current disparities that exist in PrEP access, it is critical that we improve PrEP training and education for medical students."
These studies presented at IDWeek "highlight some examples of where we can push out better education around PrEP among clinicians," Gandhi said.