PrEP prescriptions increase 1,000% in NYC, national awareness lags

SAN DIEGO — Prescriptions for pre-exposure prophylaxis (PrEP) for HIV prevention have risen almost 1,000% in New York City over the past 2 years, although socioeconomic and gender disparities in PrEP access persist, according to new research presented at IDWeek.

Other research shared at the meeting showed that nationally, PrEP awareness among health care providers remains inadequate. Experts said this knowledge gap highlights the need for increased education on the benefits of PrEP, which reduces HIV risk by more than 90%.

The CDC recommends PrEP (tenofovir/emtricitabine) for everyone at very high risk for HIV. This includes about 1.2 million Americans, of whom only 10% are currently taking PrEP, according to Rajesh T. Ghandi, MD, FIDSA, IDWeek HIV Medical Association Chair, from Massachusetts General Hospital, who moderated a press conference on the research.

Ninefold increase in NYC

An analysis of EHR records from more than 600 ambulatory care practices in New York City showed that PrEP prescriptions increased from 38.9 to 418.5 per 100,000 patients seen between the first quarter of 2014 to the second quarter of 2016 — a 976% increase.

“We found … an over ninefold increase in PrEP prescribing rates among this sample,” Paul Salcuni, MPH, study author and data analyst at the Bureau of HIV/AIDS Prevention and Control at the New York City Department of Health and Mental Hygiene, said during the press conference.

Salcuni and colleagues credited this increase to the CDC PrEP guidelines released in 2014, clinical trials and demonstration projects showing the effectiveness of PrEP, and a variety of education campaigns launched in the city.

However, an analysis of patient and practice factors revealed significant disparities in PrEP access. Although increases in PrEP prescriptions were significant for both men and women (P < .0001), the vast majority of prescriptions were among men.

“About 95% of PrEP prescriptions were among males in the second quarter of 2016,” Salcuni said.

Analysis of PrEP prescription rates by sex showed that prescriptions increased from 7.4 to 32.4 per 100,000 female patients seen during the study period, compared with 89.5 to 1,036.4 per 100,000 male patients.

Other disparities included differences in prescription rates across age groups, and between different racial and ethnic groups.

“Younger male patients and white male patients were more likely than men of color and older male patients to be prescribed PrEP among this sample,” Salcuni said.

Men aged 18 to 29 years were almost three times as likely to be prescribed PrEP than older men (adjusted rate ratio = 2.8; 95% CI, 2.4-3.4), and men of color were about half as likely to be prescribed PrEP than white men (adjusted rate ratio for black men = 0.6; 95% CI, 0.4-0.9).

Salcuni noted that among male patients, the largest relative increase in PrEP prescriptions was among black men — an almost 2,000% increase — but it was still half that of white men.

The study also showed disparities based on practice factors. Practices based in Manhattan, community health centers and practices with infectious disease specialists on site showed higher rates of PrEP prescriptions than smaller private practices and those outside of the city center.

Salcuni concluded that these data show the education initiatives in NYC appear to have had a positive impact on PrEP prescription rates, “but we need to remain vigilant and make sure that everybody who would benefit from PrEP has access to that intervention,” he said.

Lack of awareness among health care providers

Other studies highlighted the need for additional PrEP education efforts across the country, because many physicians and medical students are unaware or unsure of its benefits.

Brandon Imp, MD, internal medicine/preventive medicine resident at the Kaiser Permanente San Francisco Medical Center, and colleagues asked medical students at 18 U.S. medical schools to complete surveys on awareness, knowledge, beliefs and experiences regarding PrEP in May and June 2015. To assess their knowledge, students completed a 10-question quiz on PrEP facts.

Out of 1,588 medical students who completed the surveys, 28% were unaware of PrEP for HIV prevention. Analysis showed that 18% of students in their 4th year were never educated about PrEP in medical school compared with 40% of those in their 1st year (P < .001). According to the researchers, 57% of students thought clinicians should try behavioral intervention before prescribing PrEP, 45% thought patients would not adhere to PrEP and 22% thought that PrEP was ineffective. When students had experience caring for IV drug users or knew someone with HIV besides a patient with HIV, they were more likely to be aware of PrEP. Scoring higher on the knowledge assessment was linked to students’ confidence in determining a patient’s candidacy for PrEP, as well as having recommended PrEP in a clinical setting for 3rd and 4th year medical students.

Given the limited education medical students have on PrEP and the overall underuse of PrEP in clinical practice, the researchers recommended including PrEP more heavily in medical school education.

“This study demonstrates the limited awareness, knowledge, beliefs and experiences medical students have of PrEP for HIV prevention,” Imp told Infectious Disease News. “Responses were collected from 18 medical schools across the country, suggesting the deficit is systemic in the medical education system. Studies of clinicians have demonstrated similar findings and recommended education starting in medical school; these results further confirm the need.”

Additional research suggested the lack of awareness of PrEP is not restricted to medical students. A survey of 80 health care providers at Tufts Medical Center in Boston conducted by Rapeephan Maude, MD, MSc, now an infectious disease physician at Mahachai Hospital in Thailand, showed that about one-third had never heard of PrEP, and 32% of doctors were uncomfortable prescribing it.

“PrEP has been widely publicized in the medical literature and media, so we were surprised at the low level of awareness of its benefits,” Maude said in a press release. “Doctors often said they were uncomfortable asking their patients about risky behaviors. We think this is a major reason why some people at high risk of HIV infection are not identified.”

The survey included doctors (55%); physician assistants (20%); registered nurses (9%); medical students (8%); and medical assistants, research coordinators and physician assistant students (8%). Overall, 67.5% had heard of PrEP, and among doctors, 82% had heard of it.

Of the 32% of doctors who said they were uncomfortable prescribing PrEP, the top three barriers included not having enough knowledge (72.5%), lack of experience (56.3%) and that it was not covered by insurance (17.5%). Further, more than 75% said they would refer patients to infectious disease specialists or other providers to prescribe PrEP, which may lead to missed opportunities to start PrEP as early as possible.

Like Imp, Maude believes better education will lead to increased knowledge and improved attitudes regarding PrEP.

“Encouraging providers to work collaboratively with infectious disease specialists would increase their comfort in identifying high-risk patients and prescribing PrEP,” she said in the press release.

A similar survey performed by Brett Tortelli, BA, an MD/PhD student at Washington University, also showed a lack of knowledge and comfort regarding PrEP among emergency medicine physicians.

“Our study found that most emergency physicians were aware of PrEP, but comfort discussing PrEP with patients was low, and among emergency physicians, concerns of efficacy, side effects and drug resistance was high,” Tortelli said during the press conference.

The online survey included 88 emergency physicians at Washington University in St. Louis in 2017, of whom 67% completed the survey.

Overall, 79.1% reported they were aware of PrEP, but just 23.9% were knowledgeable of current guidelines and 22.7% were knowledgeable of referral information. Further, 53.7% were concerned about lack of efficacy, 89.6% about side effects, and 70.1% about the selection for HIV resistance.
Notably, less than half reported they were comfortable discussing PrEP (43.3%), and after adjusting for efficacy concerns, Tortelli and colleagues found that comfort discussing PrEP was significantly associated with being knowledgeable about the intervention (OR = 5.43; 95% CI, 1.19-30.81) and having referral knowledge (OR = 7.82; 95% CI, 1.93-40.98).

“The low levels of awareness of PrEP’s benefits among this group are likely due to the fact that education and outreach efforts focus on HIV and infectious diseases specialists and primary care physicians,” Tortelli said in the press release. “While emergency physicians are unlikely to prescribe PrEP because it requires continued care, they can play an important role in identifying at-risk patients — many of whom have little interaction with the health care system otherwise — and connect them to care.”

Tortelli and colleagues recommended that future provider training should address misinformation about PrEP, education on guidelines and community referral resources. – by Adam Leitenberger and Savannah Demko

References:

Imp B, et al. Abstract 879. Presented at: IDWeek; Oct. 4-8, 2017; San Diego.

Maude R, et al. Abstract 1410. Presented at: IDWeek; Oct. 4-8, 2017; San Diego.

Salcuni P, et al. Abstract 898. Presented at: IDWeek; Oct. 4-8, 2017; San Diego.

Tortelli B, et al. Abstract 1416. Presented at: IDWeek; Oct. 4-8, 2017; San Diego.

Disclosures: The authors report no relevant financial disclosures.