PrEP prescriptions low due to unfamiliarity and attitudes

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The use of PrEP remains low in primary care settings, with only 14% of residents polled at East Carolina University not even having heard of the HIV-preventive treatment.

Most resident physicians surveyed at a North Carolina medical school had heard of pre-exposure prophylaxis (PrEP), but only one had ever prescribed the medication designed to prevent HIV infection in unaffected individuals. Further, 7% of residents at East Carolina University who responded to an online questionnaire thought prescribing PrEP would increase risky sexual behaviours and 14% said they would not prescribe the treatment to patients with multiple sexual partners, researchers from the university in Greenville found. The residents cited sex workers and people who inject drugs (PWID) as patients to whom they would be less likely to offer PrEP.

“PrEP utilisation has not been what HIV care providers had hoped,” Dr Arianne Morrison, department of internal medicine at ECU, who conducted the survey, is quoted as saying. “Use by primary care providers would change that and could combat the growing epidemic the southern US is currently seeing.”

More than half of new HIV infections occur in the South despite just 37% of the US population living in the region. In 2015, North Carolina ranked 8th in new infections, Morrison and colleagues said in a presentation at IDWeek 2018 in San Francisco, the annual scientific meeting of infectious diseases professionals.

The use of PrEP, however, remains low in primary care settings. The survey found that 14% of the ECU residents polled had not even heard of the HIV-preventive treatment.

PrEP, when taken consistently, has been shown to reduce the risk of HIV infection in people who are at high risk by up to 92%, according to the US Centres for Disease Control and Prevention. In 2014, the CDC recommended the use of PrEP with daily oral dosing of tenofovir/emtricitabine for high-risk individuals.

To assess whether that message was getting out – and to determine attitudes about PrEP in rural, eastern North Carolina – Morrison and colleagues Dr Ciarra Dortche, at ECU, and Dr Nada Fadul, University of Nebraska Medical Centre, polled 149 resident physicians at ECU. The residents’ specialties included internal medicine, medicine-paediatrics, family medicine, and obstetrics-gynaecology. The survey was distributed and data were collected between March and May 2018 – 72 of those polled completed the survey.

The researchers found that 62 of the 72 residents knew about PrEP and that 69 had HIV testing available at the clinics where they practiced. Only 7% cited potential side effects as a reason to not offer PrEP. Even so, 71 of the 72 had never prescribed the treatment. The researchers found that 13.8 % of the residents did not feel comfortable discussing sexual preferences with their patients, which may have contributed to the hesitance to prescribe PrEP.

“The hardest part for resident physicians and primary care providers is having initial discussions with their patients on their sexual health and preferences and risk stratifying who would benefit from PrEP,” Morrison said. “The formation of a standardised tool to facilitate these discussions would be beneficial.”

To that point, 85% of residents said they wanted more information on PrEP and almost all would be willing to prescribe it if they received educational workshops on the treatment. Morrison said she believes her findings are similar to attitudes and PrEP use across the US. “The lack of awareness and willingness to prescribe PrEP is comparable to national findings,” she said.

Raising awareness about PrEP may be key to wider acceptance in primary care settings. “As providers know about PrEP and become comfortable with PrEP, the more it will be utilised,” Morrison said. That’s important, especially in the South, which is disproportionately affected by HIV and more recently injection drug use, Morrison said.

“The use of a novel agent to prevent HIV is critical, especially among resident physicians and primary care providers in eastern NC,” Morrison said. “PrEP has the potential to change the current direction of the HIV epidemic in the South.”

Background: North Carolina bears a high burden of HIV and was ranked number 8 for the number of new infections in 2015. In 2014, the Centers for Disease Control and Prevention (CDC) published updated practice guidelines recommending the use of pre-exposure prophylaxis (PrEP) with daily oral dosing of tenofovir/emtricitabine to help prevent HIV infection in high-risk individuals. However, the use of PrEP in the primary care setting remains low and 1 in 3 primary care physicians is not aware of PrEP. The objective of our study was to evaluate PrEP knowledge among primary care resident physicians.
Methods: 149 resident physicians were surveyed at East Carolina University from the following specialties; Internal Medicine, Medicine-Pediatrics, Obstetrics Gynecology and Family Medicine. We collected participants’ age, biological sex, current residency program, and current year within the residency program.
Results: 60 out 149 residents completed the online survey. 20% of residents had never heard of PrEP. 17% of residents did not feel comfortable discussing sexual preferences with their patients. 15% of residents thought prescribing would increase risky sexual behaviors and 12% would not prescribe PrEP to patients with multiple sexual partners. Only 3% of residents identified potential side effects of PrEP (e.g., an increase in creatinine levels or decrease in mineral bone density) as a reason to not prescribe PrEP. One resident had ever prescribed PrEP. 83% of residents wanted more information on PrEP and 95% of residents would be willing to prescribe PrEP if educational workshops were offered.
Conclusion: PrEP is an underutilized tool among resident physicians in Eastern, NC. We identified lack of knowledge of PrEP and concern for increased risky sexual behaviors as barriers to prescribing. Resident physicians require more education on PrEP in order to prescribe it to their patients.

Arianne Morrison, Ciarra Dortche, Nada Fadul

MD Mag report
ID Week 2018 abstract

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