Provider confidence in PrEP initiation associated with PrEP knowledge and attitudes
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Provider confidence in PrEP initiation, which was generally lower than other aspects of PrEP care, was associated with provider knowledge about PrEP and favorable attitudes toward PrEP, according to the results of a survey.
“HIV PrEP is an effective HIV prevention medication that was first approved in the U.S. 1 decade ago, but uptake still remains quite low among cisgender women in the U.S., particularly in the South, which is the epicenter of the domestic HIV epidemic,” Aditi Ramakrishnan, MD, MSc, assistant professor of medicine at the Washington University in St. Louis School of Medicine, told Healio. “Some of the challenges in scaling up PrEP for cisgender women include a scarcity of PrEP-providing clinics, lack of insurance support for PrEP, and lack of provider training in PrEP care.”
According to Ramakrishnan, Title X-funded family planning clinics serve as a safety-net source of health care for reproductive-age women, particularly in the South, and are, therefore, potential sites for PrEP delivery.
“In order to effectively implement PrEP care in this novel setting, one needs to understand provider training needs,” she said. “We conducted this study to evaluate knowledge, attitudes, and self-efficacy (ie, confidence in carrying out the steps) in PrEP care among providers from Title X-funded family planning clinics that did not provide PrEP in 18 Southern states in order to inform provider training in PrEP care.”
Ramakrishnan and colleagues used data from providers in clinics that did not currently provide PrEP from a web-based survey administered to Title X clinic staff in southern states between February and June of 2018.
According to the study, they then developed generalized linear mixed models to evaluate associations between provider-, clinic- and county-level variables with provider knowledge, attitudes and self-efficacy in PrEP care.
Overall, 519 providers and administrators from 283 clinics completed the survey. After excluding responses from administrators and those from PrEP providing clinics, 351 providers from 193 non-PrEP clinics were included in this secondary analysis —194 of whom were nonprescribing providers and 157 prescribing providers.
In the overall adjusted model, PrEP knowledge was positively associated with prescribing ability (0.851; 95% CI, 0.493-1.209) and negatively associated with years worked in clinic role (–0.031; 95% CI, –0.053 to –0.010). Among nonprescribing providers, there was a significant negative association with years worked in clinic role (–0.038; 95% CI, –0.078 to –0.010), whereas among prescribing providers, there were no significant covariate associations.
The average attitudes score was 3.52 and higher for prescribing vs. nonprescribing providers (P < .0001). However, scores on the attitudes subcategory of “acceptability of PrEP integration in FP settings” did not differ by prescriber status.
The researchers did find, though, that for the attitudes subcategory of clinical and socio-behavioral attitudes toward PrEP, prescribing providers had more favorable attitudes than nonprescribing providers (P < .0001).
In the overall adjusted model, PrEP attitudes were positively associated with prescribing ability (0.192; 95% CI, 0.071-0.313), and among nonprescribing providers, there were significant positive associations with on-site insurance assistance (0.180; 95% CI, 0.021-0.340) and county HIV prevalence (0.095; 95% CI, 0.004-0.186).
The overall average self-efficacy score was 3.4 and was higher for prescribing providers vs. nonprescribing providers (P < .0001). When self-efficacy survey items were grouped by the steps of PrEP care, scores were higher among prescribing providers regarding each step (P < .0001). Comparison of scores between steps indicated prescribing and nonprescribing providers were most confident in PrEP screening, less confident regarding PrEP follow-up and least confident regarding PrEP initiation (P < .0001).
They also found that self-efficacy in PrEP care was positively associated with prescribing ability (0.424; 95%CI, 0.290-0.559), attitudes toward PrEP (0.213; 95% CI, 0.094-0.332), contraception self-efficacy (0.439; 95% CI, 0.367-0.511) and negatively associated with county percent Hispanic/Latino in the population (–0.089; 95% CI, –0.162 to –0.017).
“Apart from important structural factors such as Medicaid expansion and support for Title X-funded clinics, in order for clinics to transition to providing PrEP, providers need to be equipped with tailored training,” Ramakrishnan said. “Trainings focused on PrEP initiation, particularly PrEP medication assistance/insurance support, attitudes toward PrEP care, and the integration of PrEP and family planning training may be more effective in bridging the gaps in provider training.”
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