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Providers Have Mixed Feelings About Prescribing HIV Prevention

National survey finds providers’ perspectives lag behind PrEP guidelines

Many health care providers in the U.S. are reluctant to prescribe an increasingly important prevention approach to some of their patients who are at substantial risk for human immunodeficiency virus (HIV) infection, according to survey results published in HIV Specialist.

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 survey of 324 members of the American Academy of HIV Medicine — most of whom were HIV-specializing practitioners —fewer than half reported being “very likely” to prescribe PrEP to high-risk heterosexuals or to 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 the GroupHealth Research Institute with experience counseling people with HIV infection. For other prime candidates — HIV-negative men whose male partners have the virus — 79% 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 co-author Benjamin Balderson, PhD. “But that still leaves 21% 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.”

Providers reported they were reluctant because of concerns about:

  • Patients consistently taking a daily pill
  • Regular follow-up care for monitoring and counseling
  • The effectiveness of PrEP in preventing HIV infection
  • Adverse effects
  • Patients engaging in riskier behaviors
  • The 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. “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 (Gilead Sciences), a combination of two antiretroviral medications used to treat HIV: tenofovir and emtricitabine. Truvada costs $14,400 per year, and lab costs for routine monitoring are $180 per year, so the total cost is around $40 per day. But some states, including Washington, have drug-assistance programs that cover patients’ drug costs, regardless of financial need. The generic version of Truvada is approved for use overseas, at a cost of around $2,700 per year, but it won’t be available in the U.S. until at least 2017. Other formulations are being tested, including injections, gels, and rings for women, and intermittent dosing of Truvada, such as 2 days before and after exposure.

“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,” Adams said. “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 U.S. has not declined but as held steady — at approximately 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,” Balderson said. Placebo-controlled clinical trials have shown that PrEP is a safe and effective tool for preventing HIV infection in men who have sex with men, high-risk heterosexuals, and couples in whom 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,” Adams said.

Sources: GroupHealth Research Institute; April 2, 2015; HIV Specialist; April 2015; and PrEP Guidelines; May 2014.

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