Prescribing PrEP? Don't Wait for Patients to Ask

Prescribing antivirals to individuals who are at increased risk of HIV infection can prevent the spread of HIV. Dubbed pre-exposure prophylaxis (PrEP), this approach is appropriate in men who have sex with men (MSM), HIV-discordant couples, heterosexual adults who are at elevated risk of infection, and injection drug users.

Good adherence to PrEP can reduce the risk of contracting HIV by up to 92%. Since 2012, one combination product (tenofovir disoproxil fumarate/emtricitabine) has been FDA-approved for this indication. Use of this potentially life-saving medication has been suboptimal, however.

Experts in the HIV field from across the nation have published results of a study that examined who prescribes PrEP and barriers to its prescription. Published in the journalHealth Education & Behavior, the study also looks at cost as a potential barrier.

The researchers reported that the group of people most likely to contact HIV infection—MSM—are also most likely to receive PrEP. In other high-risk groups, PrEP is often underprescribed and awareness is often low.

PrEP’s cost, identified as a significant barrier to uptake in previous studies, was estimated at more than $1000 per month for medication alone. Office visits and lab tests added to the cost. Most patients paid for their PrEP using private insurance, Gilead’s assistance program, or Medicaid, although the researchers found regional differences. In the northeast and the west, state-funded assistance programs seemed to be more available than in other regions.

The study queried health care providers who worked in the HIV field and found that involving non-physician prescribers in discussions about PrEP is critical to encouraging them to prescribe it. Physician, nurse practitioner, and physician assistant participants in this study were all equally likely to prescribe PrEP and adhere to HIV testing guidelines for people on PrEP.

The researchers pointed to growing research indicating that non-HIV specialist primary care providers should, can, and do prescribe PrEP successfully.

The key point from this research is that in the clinic, providers must initiate conversation with people who may benefit from PrEP. Provider-initiated conversations about PrEP resulted in a greater proportion of their eligible caseload receiving PrEP. It was especially effective in increasing the number of underrepresented or underreported patients (eg. women, heterosexual adults, transgender adults, people engaged in sex work, and injection drug users) receiving PrEP.

Health care providers who work in retail health clinics should consider discussing HIV and its risk factors with patients and offering PrEP when appropriate. Clinicians can find the CDC’s PrEP guidelinesonline. PrEP has the potential to transform this virus’s impact. The CDC has also published a2 page fact sheetthat summarizes many need-to-know points succinctly.

Reference

Adams LM, Balderson BH, Brown K, et al. Who starts the conversation and who receives preexposure prophylaxis (PrEP)?: A brief online survey of medical providers' PrEP practices.Health Educ Behav. 2018 Jan 1:1090198117752789. doi: 10.1177/1090198117752789. [Epub ahead of print]