Pre-exposure prophylaxis (PrEP) prescriptions in New York City increased by nearly 1,000 percent in two years, but men of color, women and patients outside the city center were less likely to be prescribed the HIV prevention medication. Taken daily, PrEP is more than 90 percent effective in reducing the risk of HIV infection and is recommended for everyone at very high risk, according to the Centers for Disease Control and Prevention (CDC).
A number of recent education campaigns and trials have demonstrated PrEP is effective, but many medical students and healthcare providers nationwide remain unaware of PrEP or are unsure of its benefits. These are among the findings on the status of PrEP use and awareness being presented at IDWeek 2017.
"Fewer than 10 percent of people who would benefit from PrEP are taking it," said Brandon Imp, MD, an internal medicine/preventive medicine resident at Kaiser Permanente San Francisco and lead author of a study on PrEP awareness among medical students. "We believe education works, but we need to do a better job throughout the country to inform future doctors as well as health providers who are on the front lines of care about the benefits of PrEP."
CDC guidelines published in 2014 recommend PrEP (emtricitabine/tenofovir disoproxil fumarate) for HIV-negative people at high risk of HIV, including: those who are in a relationship with an HIV-infected partner; gay or bisexual men who have sex without a condom or have been diagnosed with a sexually transmitted infection within the past six months; heterosexual men or women who do not always use condoms when having sex with partners at high risk for HIV; and those who inject illicit drugs. CDC recommends PrEP be used in combination with other preventative measures, including condoms.
Huge Increase in NYC PrEP Prescriptions
The prescription of PrEP rose 976 percent between 2014 and 2016, according to an analysis of electronic health records from 602 New York City medical practices, undertaken by the New York City Department of Health and Mental Hygiene.
The increase was noted after the CDC released PrEP guidelines in 2014 and as clinical trials and demonstration projects confirmed it is effective. Additionally, a variety of campaigns to educate healthcare providers about PrEP and its benefits were launched in New York City during that time. For example, the department launched a campaign in 2014 to reach out to primary care and infectious disease practices to provide them resources about PrEP, visiting more than 2,500 providers at more than 1,000 clinics throughout the city. PrEP messages were included in another campaign to encourage city residents to know their HIV status and community partner organizations have launched their own outreach efforts, say the researchers.
When analyzing the records, researchers found PrEP prescriptions were more likely to be written for younger, white, male patients and at Manhattan-based practices, community health centers and practices with onsite infectious diseases specialists. In other words, men of color, women, people getting healthcare at smaller private practices or those outside the city center were less likely to be prescribed PrEP.
"These results show that educating healthcare providers can really help improve the rate of PrEP prescribing, but it's apparent we need additional programs to ensure equitable access," said Paul Salcuni, MPH, lead author of the study and lead data analyst for prevention, Bureau of HIV/AIDS Prevention and Control at the New York City Department of Health and Mental Hygiene, Long Island City. To address the disparities, the department is planning new campaigns, including one focusing on women's health providers.
Many Medical Students Unaware of PrEP
Many medical schools aren't educating their students about PrEP and its benefits, suggests a survey of 1,588 medical students at 18 U.S. medical schools. According to the extensive survey about knowledge, beliefs and experiences, more than one in four (28 percent) medical students are unaware of PrEP and 18 percent of students in their last year of medical school were never taught about the HIV prevention regimen. Further, 57 percent believed behavioral intervention should be tried before prescribing PrEP, 45 percent believed patients would not adhere to it and 22 percent didn't think it was effective.
Studies have shown PrEP is far more effective at preventing HIV than behavioral intervention, and that while adherence is a concern for all medications, that should not deter physicians from prescribing the regimen.
"Medical students are not being taught about PrEP as they should and therefore are unaware of it, or have inaccurate beliefs about its value," said Dr. Imp, lead author of the study. "That is concerning because they are the next generation of physicians who will provide care to patients and help stem the spread of the disease. These results demonstrate the need to incorporate PrEP education into the medical school curriculum."
Doctors Often Uncomfortable Prescribing PrEP
Medical students are not the only ones who are unaware of the benefits of PrEP suggests a study of healthcare providers at one Boston hospital. According to a survey of 80 providers, including doctors (55 percent), physician assistants (20 percent), registered nurses (9 percent), medical students (8 percent) and medical assistants, research coordinators and physician assistant students (8 percent), about one-third overall had never heard of PrEP. Additionally, 32 percent of doctors said they were uncomfortable prescribing it, according to the Tufts University School of Medicine survey.
"PrEP has been widely publicized in the medical literature and media, so we were surprised at the low level of awareness of its benefits," said Rapeephan Maude, MD, MSc, lead author of the study, now an infectious disease physician at Mahachai Hospital, Thailand. "Doctors often said they were uncomfortable asking their patients about risk behaviors. We think this is a major reason why some people at high risk of HIV infection are not identified."
Some doctors said they preferred to refer patients to HIV and infectious diseases specialists, she said. While specialists have deeper knowledge about PrEP and are trained to ask about risk factors, referring patients may lead to a missed opportunity to start PrEP as early as possible. Additionally, some patients may not follow-up with a specialist, or have greater trust in their primary care doctor.
"We are confident these numbers will improve as more providers receive information on PrEP," said Dr. Maude. "Encouraging providers to work collaboratively with infectious diseases specialists would increase their comfort in identifying high-risk patients and prescribing PrEP."
Emergency Medicine Physicians Overlooked in PrEP Education Efforts
Emergency medicine physicians are generally aware of PrEP, but most aren't familiar with the CDC guidelines and many are uncomfortable discussing PrEP due to lack of awareness about its recommendations, according to a study at Washington University in St. Louis.
The study included survey results of 67 emergency room physicians who were asked about their knowledge of PrEP, including the CDC prescribing guidelines and concerns about use. Overall, 79 percent were aware of PrEP, but only 24 percent were knowledgeable about the guidelines. Additionally, 57 percent were not comfortable discussing PrEP with patients, 54 percent had concerns about whether it was effective, 90 percent worried about side effects and 70 percent feared it would promote HIV resistance. Large studies have addressed these concerns, noting that it is effective and does not promote HIV resistance. Additionally, PrEP's side effects should be discussed with patients, but benefits outweigh those issues in most cases, researchers note.
"The low levels of awareness of PrEP's benefits among this group are likely due to the fact that education and outreach efforts focus on HIV and infectious diseases specialists and primary care physicians," said Brett Tortelli, BA, lead author of the study and an MD/PhD student at Washington University. "While emergency physicians are unlikely to prescribe PrEP because it requires continued care, they can play an important role in identifying at-risk patients - many of whom have little interaction with the healthcare system otherwise - and connect them to care."
Researchers asked the physicians for their preferred method of PrEP education, and determined a variety of methods would be necessary, including educating them on the guidelines, providing existing research that would allay their concerns about PrEP and offering community resources they can use to refer patients for care.
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