Providers have mixed feelings about prescribing HIV prevention

Many health care providers across the United States may be reluctant to prescribe an increasingly important prevention approach to some of their patients who are at substantial ongoing risk for HIV. The quarterly HIV Specialist magazine of the American Academy of HIV Medicine published these survey results: "Providers' Perspectives on Prescribing Pre-exposure Prophylaxis (PrEP) for HIV Prevention."

Pre-exposure prophylaxis (PrEP) involves proactively prescribing a regimen of an HIV antiviral medication to people who do not have HIV. The medication helps prevent HIV from establishing itself and multiplying in the body.

The survey was the first to be conducted since the U.S. Public Health Service released detailed PrEP guidelines in May 2014. In the Web-based, 53-question survey of 324 American Academy of HIV Medicine members—most of whom are HIV-specializing practitioners—fewer than half reported being "very likely" to prescribe PrEP to their patients who are high-risk heterosexuals or people who use intravenous drugs.

"That's concerning, because these groups are among the prime candidates for PrEP according to the guidelines," said first author Leah M. Adams, PhD, a research fellow at Group Health Research Institute with experience counseling people living with HIV. For some other prime candidates—HIV-negative men whose male partners have the virus—79 percent of providers reported being very likely to prescribe the regimen.

"HIV-negative men in 'serodiscordant' couples were the most likely group to be prescribed PrEP in our sample," said one of Dr. Adams' coauthors, Benjamin Balderson, PhD, a Group Health psychologist and Group Health Research Institute research associate. "But that still leaves 21 percent of respondents who were not very likely to prescribe PrEP even to people in this group. Academy members are likely very aware of the indications for thinking about PrEP in this population, but something is still making them reluctant to prescribe."

Reasons for reluctance

Providers reported they were reluctant because of concerns about:

• Regular follow-up care for monitoring and counseling
• Effectiveness of PrEP in preventing HIV
• Side effects
• Patients engaging in riskier behaviors (compensating for assuming that PrEP would completely protect them)
• Cost of treatment

"Initial concerns about an increase in risky behavior, side effects, drug resistance, and adherence made providers reluctant to prescribe PrEP," said coauthor Kathy Brown, MD, Group Health's HIV program lead. "But the evidence base for PrEP use is strong—and getting stronger. Recent "real-world" studies (not clinical trials) of PrEP use do not support these concerns."

Cost remains an issue, though. The only FDA-approved PrEP is Truvada, a combination of two antiretroviral medications used to treat HIV: tenofovir and emtricitabine. Truvada costs $14,400/year, and lab costs for routine monitoring are $180/year, so total cost is around $40/day. But some states, including Washington, have drug-assistance programs that cover patient drug costs, regardless of financial need. The generic version of Truvada is approved for use overseas, at a cost of around $2,700/year, but it won't be available in the United States until at least 2017. Other formulations are being tested, including injections, gels, and rings for women, and intermittent dosing of Truvada, such as two days before and after exposure.

The big picture

"Treatment has helped to turn HIV infection into a chronic disease in most cases, and people living with HIV are more often seeing primary care providers instead of infectious disease specialists," said Dr. Adams. "But too many people have the mistaken impression that the HIV epidemic is over." In fact, for the past decade, the rate of new HIV infections in the United States has not declined but held steady—at around 50,000 new cases a year.

"PrEP promises to help to curb the rate of new HIV infections as part of a comprehensive prevention plan—including safer sex, regular 'opt-out' HIV testing, risk reduction counseling, and treatment of any other sexually transmitted infections," Dr. Balderson said. Placebo-controlled clinical trials have proven PrEP to be a safe and effective tool for preventing HIV infection in men who have sex with men, high-risk heterosexuals, and couples where one partner is living with HIV.

"Our findings emphasize that health care providers need ongoing education and guidance about how to deal with practical issues associated with prescribing PrEP," Dr. Adams said.

The American Academy of HIV Medicine funded the study and asked the Group Health team to conduct the survey to assess some of their members' perspectives on using PrEP in their practices. Some Academy members are PhDs who study HIV but can't prescribe medication, so survey results were analyzed for only the subset of members who can do so: mostly primary care providers, internal medicine, and infectious disease specialists who see a mix of patients, some with the virus and some without it. The research team looked for regional variations but didn't find many significant ones.

"Most of our member clinicians are savvy HIV treaters who read the literature and have a keen understanding of what's available to them in the prevention toolbox," said coauthor Bruce J. Packett, II, deputy executive director of the American Academy of HIV Medicine, in Washington, DC. "Gauging attitudes and behaviors of those providers on the front lines with respect to PrEP is a key pressure point in moving towards the routine use of effective, safe and well-targeted biomedical interventions in the fight against new HIV transmissions in the US."