Most people who would benefit from pre-exposure prophylaxis (PrEP) are unlikely to seek care from an HIV specialist. Primary care providers (PCP) are therefore well positioned to screen for and prescribe PrEP, a review of studies on PCP attitudes towards biomedical HIV prevention published in the Journal of General Internal Medicine has noted. Yet, many feel ill equipped to prescribe what they perceive as an HIV medication, the authors said.
They identified six other barriers to PrEP implementation in primary care:
- Impression of low effectiveness because of suboptimal results in some trials due to low adherence
- Time constraints during routine care visits precluding sexual risk assessment
- Concerns about affordability of the medication for some patients
- Worry about drug resistance if patients seroconvert
- Fear of renal and bone density issues related to the drug
- Concern about behavior changes that would put patients at risk of acquiring other sexually transmitted infections
This last concern was more common among the 65.1% of respondents to another study published in the Journal of General Internal Medicine who did not prescribe PrEP than among their prescribing colleagues. Other characteristics of PrEP adopters included caring for 50 or more people living with HIV and rating one's own knowledge of this biomedical prevention method as at least "good."
However, as Natasha Parekh, M.D., pointed out in a commentary on the study, self-reported knowledge does not necessarily mean actual knowledge. The lack of knowledge about PrEP that Parekh speaks to is also supported by a small survey of PCPs in Springfield, Massachusetts, reported at ID Week 2017. It found that 45% of the already small number of respondents who had raised PrEP with men who have sex with men (MSM) in their care correctly answered a question about the U.S. Centers for Disease Control and Prevention's (CDC) indications for PrEP. The 34.1% of respondents who had received training on MSM-specific care did no better than their colleagues who had no training.
Provider education is one of four actions that Richard E. Greene, M.D., a PrEP-prescribing PCP, proposed in the American Journal of Public Health to expand the reach of PrEP. The others are:
- Routine screening for PrEP, possibly linked to offering an HIV test during each patient visit because people's sexual behavior changes over time
- Discussing the risk of acquiring HIV to enable patients to make informed decisions
- Removing financial barriers to PrEP access
He also identified a harder-to-overcome barrier: "Health care providers carry many of their own biases, and many do not want to change their practices, especially around a new medication that might remove fear and stigma associated with behaviors that are traditionally laden with fear and stigma." That, however, is a whole other discussion.