A large proportion of physicians in the U.S. still don't know how they feel about the use of pre-exposure prophylaxis (PrEP), according to a study presented at IDWeek 2014.
The study, which surveyed 105 clinicians and was developed by a team at Walter Reed National Military Medical Center, found that the physicians knew little about PrEP -- most of their answers on the survey were incorrect. Few of the physicians had actually prescribed PrEP and many did not think it was a cost-effective intervention. The team concluded that programs should be developed to train providers prior to prescribing -- and that organizations might want to restrict prescribing of PrEP to clinicians with significant experience treating HIV.
Other poster presentations addressed some of these issues, however. One found that trained staff at an urban HIV clinic in Houston, Texas, could successfully deliver PrEP to MSM and high-risk heterosexuals in context of comprehensive preventive services , though some dropped out over time. Meanwhile, a modeling study suggested that PrEP would be much more cost effective if targeted to the highest-risk individuals.
However, another poster reported that opportunities to prescribe PrEP to just such a population receiving care at the Fenway Institute in Boston -- individuals who go on multiple courses of non-occupational post-exposure prophylaxis (NPEP) because of high-risk activity -- were being missed. It only makes sense to transition such individuals from NPEP to PrEP, but according to a survey of the patients, it wasn't happening either because clinicians were not telling their patients about PrEP, or because people were afraid to discuss their sex lives with their doctors. However, interest in PrEP was increasing in this group over time.
Each year in the U.S., there are around 50,000 new HIV infections, but in July 2012, the U.S. Food and Drug Administration (FDA) approved another tool for HIV prevention: tenofovir/emtricitabine (Truvada) as PrEP.
There has been some division within the HIV community regarding the use of PrEP, and its uptake of PrEP, at least initially, has been slow. However, the data appear clear that when PrEP is taken as recommended, Truvada has good efficacy at preventing HIV acquisition. If adherence has been an issue in clinical trials, what will happen in clinical practice -- and how might provider knowledge and views of PrEP affect this?
The Provider Survey
In order to ascertain providers' knowledge, perceptions, and attitudes on the applicability and utility of PrEP, and determine the prescribing patterns among two cohorts of primarily infectious disease doctors, the team at Walter Reed developed a 34-question survey using Survey Monkey, an online survey site which collects data anonymously. After first being piloted in five physicians to establish clarity and functionality, the survey was rolled out in 2013 to two cohorts of infectious disease staff and trainees: the Armed Forces Infectious Disease Society (AFIDS) and the Greater Washington ID Society (GWIDS). A total of 105 doctors participated, mostly working in infectious disease and as military academics.
The survey asked questions like:
- Do you feel the current literature supports the use of PrEP? (Almost 70% said no.)
- Do you feel the cost of PrEP is justifiable? (Only a quarter thought that it was.)
Providers at military treatment facilities were also asked to whom they thought PrEP should be offered.
- Patient who is sexually active with multiple partners. (Around 15% answered yes.)
- HIV-negative man trying to impregnate. (About 70% answered yes.)
- HIV-negative woman trying to conceive. (More than 80% answered yes.)
- Patient with a new sexually transmitted infection in the last 6 months. (Less than 20% said yes.)
- Monogamous heterosexual. (About 60% said yes, and roughly the same amount said the same thing for monogamous men who have sex with men.)
Results were very similar for providers at civilian hospitals. Overall, based on the 2011 U.S. Centers for Disease Control (CDC) interim guidelines, 60% of knowledge questions were incorrect. However, doctors who spent at least a quarter of their time providing HIV care had a significantly higher percentage correct.
There was limited experience using PrEP: 77% had never prescribed PrEP, and the remainder had only prescribed it to one to five patients.
The poster's authors noted that another survey's results, which were published earlier this year, found that the majority of adult infectious disease physicians across the U.S. and Canada supported PrEP, but that there were vast differences of opinion and practice.
"Success of real-world PrEP will require multidimensional programs addressing these barriers," the team from Walter Reed concluded.
Issues of Cost and Implementation in Other Studies
However, some programs are already sorting these issues out. At the HIV clinic in Houston, individuals presenting for HIV testing and counseling are screened to determine their risk for HIV acquisition.
Out of 381 walk-in HIV tests performed from May 2013 to May 2014, 58 individuals (15.2%) were deemed at to be at highest risk for HIV infection, and agreed to an appointment in the HIV prevention clinic.
Fifty of these patients (94%) were in a serodiscordant relationship, 10 (19%) identified as MSM (men who have sex with men), and 49 (92%) had reported unprotected sex.
Notably, over half the patients in the prevention clinic (57%) were women.
In total, 36 patients (61%) attended their first appointment, 23 patients (40%) completed at least one follow-up appointment, and 20 patients (34%) started PrEP. There have been no HIV infections among these patients to date.
Payment issues were largely sorted out for the patients -- most (70%) of these patients relied on Harris Health System programs for subsidized cost of medical care. Four individuals (17%) had Medicaid and three (13%) had private insurance, while 10 received medication from the pharmaceutical assistance program.
According to a cost-modeling study of researchers in Toronto and London, the cost of treating every MSM in Toronto with PrEP would indeed be high, with costs per quality-adjusted life year (QALY) increasing from $230,000 to $300,000. However, by optimizing adherence and efficacy, and targeting PrEP primarily to reach 25% of the MSM at highest risk, with HIV testing every 3 months, a $32,000 cost per QALY was achieved.
From NPEP to PrEP
Among those most obviously at high risk, are people who recurrently present for NPEP due to high-risk behavior, but there has been little data about whether or not these individuals are being transitioned to PrEP.
So researchers in Boston conducted a survey of a convenience sample of participants enrolled in an ongoing NPEP study at Fenway Health, a large urban community health center from May 1, 2013 to March 30, 2014. The study included 45 individuals, mostly MSM of around 35.3 years of age.
On day 14 of being on NPEP, participants were queried about their baseline knowledge of PrEP, interest in using PrEP, where PrEP could be accessed and barriers to PrEP use. On day 90 of the study, participants were queried again.
Almost a quarter had never heard of PrEP, but most had heard of it at least 6 months or a year ago. However, of the 80% with a primary care physician (PCP), a third did not feel comfortable talking to their PCP about PrEP; 58.3% cited not being comfortable discussing sexual practices. Most thought that they would be more likely to obtain it from either an STD clinic, LGBT clinic or an HIV care provider.
About a fourth of those who completed the NPEP study were referred to PrEP.
The majority of NPEP users reported a high interest in using PrEP, especially after using NPEP -- which suggests that linkages should be strengthened between NPEP and PrEP programs.
Given the reticence among the patients to discuss PrEP or their sexual activity with their primary care provider, the authors concluded that doctors should be encouraged to proactively discuss PrEP with NPEP-experienced patients.
Theo Smart is an HIV activist and medical writer with more than 20 years of experience. You can follow him on Twitter @theosmart.