Making PrEP More Integrated and Available for Primary Care Providers to Prescribe in the U.S. Southeast

An Interview With Jessica Seidelman, M.D.

Contributing Editor
Jessica Seidelman, M.D.
Jessica Seidelman, M.D.

Although tenofovir/emtricitabine (Truvada) has been approved for HIV pre-exposure prophylaxis (PrEP) in the U.S. since 2012, and despite an increase in PrEP uptake, the struggle persists to inform primary care providers about PrEP and to make them comfortable with prescribing the medication to those who stand to benefit most. As Jessica Seidelman, M.D., and her North Carolina-based colleagues found, in the region hardest hit by the HIV epidemic, even a great percentage of providers affiliated with a large university hospital system do not prescribe PrEP -- or assess whether their clients might need it.

At AIDS 2016 in Durban, South Africa, I spoke with Seidelman, an infectious disease fellow at Duke University in Durham, North Carolina, about her study of providers' knowledge, attitudes and beliefs about PrEP in Duke's network of primary care clinics in the Southeastern U.S.

Welcome, Dr. Seidelman. Tell me about your study.

We know that HIV is a huge problem in the Southeast. We also know that several studies have looked at patient sentiments and feelings towards taking PrEP.

The question that hasn't been answered, though, is, "Are primary care providers ready and willing to prescribe PrEP" -- as we know that many patients so desperately want them to.

We surveyed a bunch of primary care providers in our Duke University network; 115 responded. We asked them:

  • Do you know what PrEP is?
  • If you do, have you prescribed PrEP?
  • Why or why not?
  • What are your barriers to prescribing PrEP?

What we found is that 17% of our primary care physicians had prescribed PrEP -- which is pretty high, I think, for primary care providers. But when we asked people, "Why haven't you prescribed PrEP?" about 60% said, "Well, we don't know a whole lot about it." Specifically, when we asked them, "What would make you more likely to prescribe PrEP?" they said, "We want more training [74%] and educational materials [55%], maybe an infectious disease consultant on hand [26%] or a specific infectious disease clinic that we can refer people to."

That was a big takeaway: How can we make PrEP more easily integrated and available for primary care providers to prescribe? What we have done this year so far, which is really exciting, is we've started a specific PrEP clinic. Our hospital uses Epic software, which is great. What we can do is, primary care providers can type "PrEP" into an order set, and it will automatically refer patients to this PrEP clinic that we have.

The PrEP clinic will not only consist of seeing an infectious disease specialist, but also support from social workers to get financial aid, so clients can get the medication that they need. It's kind of a package deal.

We've also started going out to all of these primary care clinics to educate primary care providers, so we can hopefully get the 17% number up even more. We're also going to do a follow-up study, hopefully within the next year or so, to see how people have responded to those educational sessions.

Regarding the primary care providers who have actually prescribed PrEP: Where did they report getting information about it?

A lot of them, actually, were residents. They're newly trained primary care physicians that are a little more up-to-date in terms of the newer treatments that are out there. That was probably the majority of people that were prescribing PrEP.

Is there any speculation as to whether having people go somewhere other than their primary care physician for PrEP will lead to lack of follow-up because they've had to take another step and go offsite?

Exactly. We really want to empower primary care providers to start prescribing PrEP on their own. We don't want to create another barrier to patients -- namely, needing to travel a long way or to go to a provider they're not comfortable with. The hope is that we can bridge these folks back to the primary care physicians and eventually not need necessarily to do the offsite PrEP clinic at all.

There will always be those patients who have poor kidney function or that are a little more complicated in terms of coinfections. That's really what the PrEP clinic is going to be there for: the patients whose cases are a little more complicated. The educational sessions for primary care providers are also going to say, "When should you maybe refer patients that are asking for PrEP to this specific clinic?" But the hope is that, with more simple, straightforward patients that just want PrEP, they can go to their primary care providers.

Are there any other takeaways that you'd like to share with clinicians outside of Duke's network area or in other parts of the South?

One of the biggest takeaway messages that we got is when we asked providers, "Do you ask about sexual preference and high-risk sexual behaviors?" Surprisingly -- or perhaps not too surprisingly -- 50% of primary care providers were not asking these specific questions. Again, that speaks to the educational piece: We need to really push primary care providers to ask these questions and to really target who would need this medication. We can't prescribe PrEP if we don't know who we need to target, and ask.

Any final thoughts?

I think that, as I said, this educational piece is going to be huge. We really want to get the message out there that PrEP works; we know it does. We want to empower primary care providers to be able to say to their patients, "This is something that you can take."

This transcript has been edited for clarity.