Putting PrEP into Practice: Lessons Learned from Early-Adopting U.S. Providers' Firsthand Experiences Providing HIV Pre-Exposure Prophylaxis and Associated Care.

Sarah K Calabrese,Nathan B Hansen,Kenneth H Mayer,Kristen Underhill,Douglas S Krakower,Manya Magnus,Lauren A Gaston Hawkins,Adam I Eldahan,Trace S Kershaw,John F Dovidio,Joseph R Betancourt,Linda Anne Selvey

doi:10.1371/journal.pone.0157324

Abstract

Optimizing access to HIV pre-exposure prophylaxis (PrEP), an evidence-based HIV prevention resource, requires expanding healthcare providers’ adoption of PrEP into clinical practice. This qualitative study explored PrEP providers’ firsthand experiences relative to six commonly-cited barriers to prescription—financial coverage, implementation logistics, eligibility determination, adherence concerns, side effects, and anticipated behavior change (risk compensation)—as well as their recommendations for training PrEP-inexperienced providers. U.S.-based PrEP providers were recruited via direct outreach and referral from colleagues and other participants (2014–2015). One-on-one interviews were conducted in person or by phone, transcribed, and analyzed. The sample (n = 18) primarily practiced in the Northeastern (67%) or Southern (22%) U.S. Nearly all (94%) were medical doctors (MDs), most of whom self-identified as infectious disease specialists. Prior experience prescribing PrEP ranged from 2 to 325 patients. Overall, providers reported favorable experiences with PrEP implementation and indicated that commonly anticipated problems were minimal or manageable. PrEP was covered via insurance or other programs for most patients; however, pre-authorization requirements, laboratory/service provision costs, and high deductibles sometimes presented challenges. Various models of PrEP care and coordination with other providers were utilized, with several providers highlighting the value of clinical staff support. Eligibility was determined through joint decision-making with patients; CDC guidelines were commonly referenced but not considered absolute. Patient adherence was variable, with particularly strong adherence noted among patients who had actively sought PrEP (self-referred). Providers observed minimal adverse effects or increases in risk behavior. However, they identified several barriers with respect to accessing and engaging PrEP candidates. Providers offered a wide range of suggestions regarding content, strategy, and logistics surrounding PrEP training, highlighting sexual history-taking and sexual minority competence as areas to prioritize. These insights from early-adopting PrEP providers may facilitate adoption of PrEP into clinical practice by PrEP-inexperienced providers, thereby improving access for individuals at risk for HIV.

Highlights

45,000 Americans are newly infected with HIV every year [1], highlighting the need to expand the menu of prevention options routinely offered to at-risk individuals in medical care
A number of theoretical and practical barriers to providing pre-exposure prophylaxis (PrEP) have been reported by providers, with the following six being especially prominent: uncertainty about financial coverage/reimbursement for PrEP-related costs (Barrier 1); logistical concerns around PrEP implementation, including the burden of ongoing laboratory testing and time required for risk and adherence counseling (Barrier 2); challenges with determining patient eligibility, including anticipated difficulty applying risk criteria and eliciting an accurate sexual history from patients (Barrier 3); concerns about patient adherence to daily medication and follow-up appointments (Barrier 4); discomfort exposing otherwise healthy individuals to potential medication side effects when other prevention options are available (Barrier 5); and apprehension about patients increasing their risk-taking behavior with PrEP use [7,8,9,10,11,12,13,14]
Most participants had prescribed PrEP as part of their clinical practice, and a substantial minority had prescribed as part of a research study

Summary

Introduction

45,000 Americans are newly infected with HIV every year [1], highlighting the need to expand the menu of prevention options routinely offered to at-risk individuals in medical care. Oral antiretroviral pre-exposure prophylaxis (PrEP) has been shown to be a well-tolerated and effective method of protection in multiple clinical trials and demonstration projects [2] and should be included among the health services provided to patients at risk for HIV due to sexual behavior, injection drug use, or both. A number of theoretical and practical barriers to providing PrEP have been reported by providers, with the following six being especially prominent: uncertainty about financial coverage/reimbursement for PrEP-related costs (Barrier 1); logistical concerns around PrEP implementation, including the burden of ongoing laboratory testing and time required for risk and adherence counseling (Barrier 2); challenges with determining patient eligibility, including anticipated difficulty applying risk criteria and eliciting an accurate sexual history from patients (Barrier 3); concerns about patient adherence to daily medication and follow-up appointments (Barrier 4); discomfort exposing otherwise healthy individuals to potential medication side effects when other prevention options are available (Barrier 5); and apprehension about patients increasing their risk-taking behavior with PrEP use (i.e., risk compensation; Barrier 6) [7,8,9,10,11,12,13,14]

Methods

Results

Conclusion