Many studies have tried to answer why pre-exposure prophylaxis (PrEP) uptake is low even in communities that are heavily impacted. But it's not just a question of the willingness of people who may be most at risk of acquiring HIV. One of the barriers may be that primary care providers are still not sure if they can or should prescribe it. To find out what barriers primary care docs may have, Anthony J. Santella, Dr.P.H., M.P.H., MCHES, professor at Hofstra University in Long Island, New York, presented a poster at the National HIV Prevention Conference in Atlanta in March entitled, "Knowledge, Attitudes, and Willingness to Prescribe PrEP Among Primary Care Providers from the Largest Suburban HIV Epidemic in the United States."
Terri Wilder: If you wouldn't mind, take us through your study, telling us what it's about, what your methods were, your results and your conclusions; and what your information could have, in terms of application in the real world.
Anthony J. Santella: Long Island, New York is made up of both Nassau and Suffolk counties. Together, Nassau and Suffolk counties do make up the largest suburban HIV epidemic in the U.S. Long Island is a unique place. While we're only 20 miles outside of New York City, it's a completely different world. We have dense geography, lack of public transportation, highest rates of racial segregation. So it's leaving a lot of vulnerable populations without key prevention resources like PrEP. And while PrEP has been around for, you know, seven years now, uptake remains low in our geographic area.
We also know that there's been a body of research that shows primary care providers have had a low-to-moderate knowledge when it comes to PrEP. And so what we did was we implemented an online survey of primary care providers affiliated with one of our two major health systems, Northwell Health and Stony Brook Medicine. We surveyed primary care providers on PrEP awareness, comfort with PrEP (comfort with prescribing PrEP), experience with PrEP, and limitation and barriers to prescribing PrEP.
We had a sample of 341 providers made up of a mix of resident physicians, attending physicians, PAs [physician assistants] and NPs [nurse practitioners], and they came from different subspecialties of primary care, which include internal medicine, urgent care, OB/GYN [obstetrics and gynecology], family medicine, and adolescent medicine, and some others not identified above. Of the 341 providers, 53 identified as female, 80% as non-Hispanic, 52% white, and a large majority non-gay-identifying.
Ultimately over half, 53%, reported little to no experience treating LGBT persons. And the majority hadn't ever prescribed PrEP. And out of the remaining 25%, or about 80 providers, the majority had only done a few prescriptions. In fact, 14% of our 341 providers had never even heard of PrEP.
The most common barriers cited to lack of PrEP prescriptions included lack of training, low awareness of PrEP guidelines, and lack of patient requests. Providers also said about 40% were concerned about potential PrEP side effects. They also thought it was more of an HIV clinic issue than a primary care issue, and that behavioral interventions, particularly education interventions, should be done and attempted before prescribing PrEP.
And so while this provides us good information, we have to now do something about it. And so our next steps are to convene a group of early adopters across provider subtypes and primary care specialties, to have them be champions and key stakeholders, in terms of kind of infiltrating their respective groups.
TW: I guess I'm a little shocked that 14% had never heard of PrEP. And I'm just wondering if you can give a little insight into that. I mean, I realize that you talked about their primary care specialty being internal medicine, urgent care, OB/GYN, family medicine, and adolescent medicine. And then you had this huge group of people who, unfortunately, didn't identify what their primary care specialty was.
But I guess it's easy for folks who work in HIV, because we see all the messages. We're on all the emails. We see all the social media. But do you have any explanation as to why you think that 14% had never heard of it, even though the Food and Drug Administration approved Truvada for PrEP in July of 2012?
AJS: So, you know, that's an interesting subanalysis, which is on my to-do list, to pull out those 14% to see what their characteristics are. And we haven't done that yet, but that is a next step.
You know, I have a few reasons for that. One, it could just be that the survey was voluntary, so people could just be, like, "Whatever. I'm just doing it for the incentive," or for other kind of non-altruistic reasons.
But a lot of people -- I heard this, and it's kind of shocking from providers -- don't even associate the HIV prevention pill with PrEP. Just like the basics -- what it is, what it stands for, what it means. And so there's a disconnect there with some basic messages. So while a lot of emphasis has gone to the guidelines and understanding the clinical aspects of PrEP, we might have to take a few steps back and go back to the basics -- which is not something that we normally associate with clinicians but might be warranted, in this case.
TW: I think it would be really important to find out who these folks are. I also think it's interesting in your findings that 32% actually thought it was more feasible to provide PrEP in primary care clinics versus HIV clinics.
AJS: And so if you flip that around, two-thirds think it should be an HIV clinic issue. Now, I will say the majority of participants did come from the one health system, Northwell Health, where they house one of the largest, if not the largest, adult HIV clinics in New York State. And so a lot of the providers may think, "Well, we have this HIV center within our big medical campus, so why should we do it when they could just go there?"
We're never going to change the numbers of PrEP users in our area if that's the mentality. And so we will be partnering with that adult HIV clinic to get them on board, saying, "We're here to help, but this is not -- we're not going to service every single person who needs PrEP in our area."
TW: The messages from the New York City Department of Health (which I'm recognizing doesn't fall under your jurisdiction) but also the New York State Department of Health are that PrEP is a primary care issue. And just like you wouldn't withhold a statin from a patient that needed it, you wouldn't withhold PrEP. You know, you're getting into kind of murky waters -- now we're talking about malpractice.
So it's interesting, because this is about behavior change, knowledge change, perception change. And the great thing about New York State, as you know, that's different from maybe other states in the country is that New York State not only has the AIDS Education Training Center (AETC), but the New York State Department of Health has the Clinical Education Initiative. So they have all these free resources and tools available to medical providers across the State of New York. And I guess it's really trying to figure out how to get to the right folks, instead of maybe just constantly preaching to people who've already kind of drunk the Kool-Aid.
AJS: I think we are preaching to the choir, number one. Number two is, beyond the resources you mention, we also have PrEP-AP in New York State, which will pay for a lot of the surrounding fees and costs associated with going on PrEP. I think one of the key messages for me is we have to take a few steps back, and not assume because someone is a physician or a nurse practitioner or a physician assistant that they know everything about this. Because they certainly don't. And embedding and trying to change the training programs for the medical schools and nursing schools, the PA programs, to embed sexual health in primary care. It's not just one thing that gets an hour over the course of four years of medical school; it's primary care. And that's hard to change when a lot of those educators, like my colleagues, are of the mentality and of the school of thought that it's something different: It's infectious disease. It's not what we do.
It is what we do. And it's what we should be doing.
TW: I will be very interested about your subanalysis regarding these 14% who had never heard of it. You know, when you talked about your sample and what provider type they were, you have a pretty hefty number of resident physicians that took the survey. And so I'm curious. You know, are the folks who are more likely to have never heard of it -- were they residents? I could see your point; maybe they only got, you know, 25 minutes on PrEP and that was it. But I would be even more concerned if it was attending physicians, physician assistants, nurse practitioners, that have been practicing.
AJS: We looked at provider type. And there were no statistically significant differences in their attitudes. We actually held off on the resident physicians till the second wave of surveys because we didn't want them to dominate. And we had limited incentives, because it was from our budget. So we tackled attending physicians, NPs, and PAs first. And then, after they had gotten one or two reminders, then we added in the resident physician bunch. But there weren't statistically significant differences.
You would think there would be, because they're younger, probably more accepting attitudes of LGBT persons and gender [or] sexual minorities, in general. But in this case, no.
TW: So, it sounds like having a great strategy to kind of take this data that you have and really put it into linking people to these resources, not only around PrEP, making sure people are aware of it, making sure there's no confusion about that this is a primary care issue, making sure people understand that PrEP side effects are really nothing to prevent you from prescribing, that behavioral interventions are a package with PrEP, that it's not siloed.
You reported that a little over half reported little to no experience treating LGBT patients. So, if there was an intervention with clinical education, would it not only just mean about PrEP, but also is there a need for providing culturally competent care for LGBT patients?
AJS: Yeah. And I think with that question in particular, a lot of people make assumptions about people's gender or sexual orientation. Both these health systems in the last year or two have made a conscious effort to collect better data and not make assumptions by the way someone looks, or that their sexual orientation equals their behavior and those kinds of things.
So it's gotten better. But it's not perfect.
And these are both major academic medical centers that you would think would be doing best practices when it comes to data collection but traditionally haven't been. But they are making steps in the right direction.
Terri L. Wilder, M.S.W., has been part of the HIV community since 1989. She served on the New York Governor's Task Force to End AIDS, was recognized by POZ magazine for her work in HIV, and is highlighted in the book Fag Hags, Divas and Moms: The Legacy of Straight Women in the AIDS Community by Victoria Noe. She loves this community and will keep fighting until the epidemic is over.