Lack of clinical training, HIV misconceptions are barriers to PrEP in the South

In a recent survey, most primary care physicians in the South were not screening patients for HIV preexposure prophylaxis eligibility or writing prescriptions for it.

A lack of clinical training and misconceptions surrounding HIV resistance to pre-exposure prophylaxis (PrEP) were among the barriers toward screening and prescribing, the survey found.

Presenting at the American Osteopathic Association’s OMED conference, Daryl O. Traylor, MS, MPH, PhD, a medical student at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio, noted that while PrEP “is highly effective against HIV when taken as prescribed,” only 953 African Americans in the South received PrEP prescriptions in 2018.

“Primary care providers are missing key opportunities to screen for PrEP need, as well as prescribe PrEP,” he said, noting that research on barriers remains muddled.

In the U.S., HIV is most prevalent in the South. According to the CDC, from 2015 to 2019, the South accounted for 96,000 new HIV infections, 58,100 more than the West, the second-highest region. African American patients are disproportionately affected, making up more than half of all new infections from 2018 to 2019, Traylor said.

For the cross-sectional study, Traylor used the Transtheoretical Stages of Change Model to examine patterns and characteristics of PrEP assessments and prescribing in primary care practices in the Southern U.S.

The study cohort included 223 PCPs across 10 Southern states who had a mean age of 44 years; 57.8% were men (n = 129). More than half of the participants practiced in Texas, and the majority practiced in an urban setting.

Traylor found that 32.3% of PCPs (n = 72) did not prescribe PrEP and did not intend to prescribe PrEP within 6 months, while 16.6% (n = 37) did not prescribe PrEP but intended to within 6 months. About thirty percent (n = 69) had prescribed PrEP for more than 6 months.

According to participants’ responses — which were ranked using a Leichter scale of 1 (not important) to 5 (extremely important) — the most significant barriers to prescribing PrEP included:

• a lack of provider training on PrEP (mean score, 4.27);
• a lack of clinical guidelines on PrEP (mean score, 3.87);
• staffing and time constraints (mean score, 4.29); and
• a lack of insurance coverage and high out-of-pocket costs (mean score, 4.7).

Notable facilitators included patient motivation (mean score, 4.25) and access to PrEP resources (mean score, 3.63), Traylor said. Meanwhile, gay, bisexual and lesbian patient characteristics were among the most negative variables predicting the prescription or nonprescription of PrEP.

Traylor also reported that PCPs with 50% or more African American patients were more likely to have prescribed PrEP compared with those who had 50% or less African American patients (73% vs. 37%). Meanwhile, 63% (n = 115) of PCPs who had 50% or fewer African American patients never prescribed PrEP.

Traylor concluded that both a lack of provider training and clinical guidelines, along with misconceptions surrounding PrEP and HIV resistance highlight “a need for more physician education.”

References:

• HIV in the United States by region: HIV incidence. https://www.cdc.gov/hiv/statistics/overview/incidence.html. Accessed Nov. 2, 2022.
• Traylor, D. PrEP prescribing by Southern U.S. Primary Care Providers. Presented at: OMED22; Oct. 27-31, 2022; Boston.