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Most ID physicians support PrEP but with differing views on practice
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Most adult infectious disease physicians support pre-exposure prophylaxis, or PrEP, but have varying differences of opinion and practice, despite CDC guidelines, according to recent data published in Clinical Infectious Diseases.
“Ever since the studies demonstrating the efficacy of PrEP in MSM and serodiscordant couples, I was sold on the use of PrEP as another strategy to help curb the spread of HIV,” Maile Karris, MD, assistant professor of medicine at the University of California, San Diego, told Infectious Disease News. “I also believed my peers had similar views, but learned that other HIV providers in the community had very divergent thoughts about ideal candidates for PrEP. This led to the current study to determine the actual opinions and practices of PrEP among infectious disease physicians in the United States and Canada.”
Maile Karris
Karris and colleagues sent an electronic survey to members of the Infectious Diseases Society of America’s Emerging Infections Network (EIN) in June. Of the 1,175 active members, 573 responded to the survey within a month. The survey included 10 questions about the provider’s opinions on PrEP.
Seventy-four percent of respondents supported PrEP. However, only 9% of physicians had actually provided PrEP, and 43% said they had not provided it, but would. Fourteen percent of the physicians said they would not provide PrEP. The most common reasons for not providing PrEP included concerns about adherence and the risk for future resistance, concern about cost and reimbursement, concern about giving potentially toxic drugs to healthy people and a belief that there was insufficient evidence about its efficacy.
Most said they would provide PrEP to those with risk factors and/or if their patient requested it. The main risk factor to prompt PrEP was a partner with HIV not receiving therapy. Others included unprotected sex, multiple sex partners and patients with a partner receiving antiretroviral therapy.
There also was significant variation in use of HIV nucleic acid testing for patients on PrEP and ways to measure PrEP adherence. Lastly, some of the same reasons physicians gave for not prescribing PrEP were perceived as barriers to PrEP, including cost, drug resistance, efficacy and giving a toxic drug to healthy people. Some also stated concerns about the cost-effectiveness of PrEP, whether or not PrEP should be considered an issue for primary care providers and whether the patients at highest risk would seek PrEP.
“I hope that the data highlighting the differences in provider practice will assist in the future development of formal PrEP guidelines to allow effective and efficient provision of PrEP and minimize potential abuses of PrEP, such as risk compensation and the development of future resistance,” Karris said.
Karris said that the data pose several additional research questions, some of which are currently being studied. These research topics include the development of effective strategies to overcome the barriers to PrEP and the investigation of novel strategies that may improve the cost-effectiveness of PrEP. — Emily Shafer
Maile Karris, MD, can be reached at: Department of Medicine, University of California, San Diego, 200 W. Arbor Drive #8208, San Diego, CA, 92103-8208; email: m1young@ucsd.edu.
Disclosure: Karris reports no relevant disclosures.
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Carlos del Rio, MD
This is an interesting and important survey that demonstrates what we are seeing in PrEP implementation. ID physicians know the data but are reluctant to prescribe it because of concerns of risk compensation, poor adherence and development of resistance that have not shown to be the case. However, such reluctance is not all that unusual. When novel technologies that change the paradigm appear, there is an implementation lag-time. As with the diffusion of new technologies, there will be opinion leaders who will become early adopters and then there will be a "trickle-down" effect until the technology is incorporated into the market. An important driving force will be potential users who will demand the new technology. In that respect, I believe that general practitioners and other primary care providers, rather than ID physicians, will eventually become the major prescribers of PrEP.
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