Elsevier

Preventive Medicine

Volume 130, January 2020, 105875
Preventive Medicine

HIV prescriptions on the frontlines: Primary care providers' use of antiretrovirals for prevention in the Southeast United States, 2017

https://doi.org/10.1016/j.ypmed.2019.105875Get rights and content

Highlights

  • Less than one-third of providers prescribe antiretrovirals (ARVs) to prevent HIV.

  • Providers with poor understanding of ARVs did not prescribe them to patients.

  • Providers familiar with one type of ARV likely prescribe other types to patients.

Abstract

HIV disproportionately affects persons in Southeast United States. Primary care providers (PCPs) are vital for HIV prevention. Data are limited about their prescribing of antiretrovirals (ARVs) for prevention, including non-occupational post-exposure prophylaxis (nPEP), pre-exposure prophylaxis (PrEP), and antiretroviral therapy (ART). We examined these practices to assess gaps. During April–August 2017, we conducted an online survey of PCPs in Atlanta, Baltimore, Baton Rouge, Miami, New Orleans, and Washington, DC to assess HIV-related knowledge, attitudes and practices. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) were used to estimate correlates of nPEP, PrEP and ART prescribing practices. Adjusting for MSA and specialty, the weighted sample (n = 820, 29.6% adjusted response rate) comprised 60.2% white and 59.4% females. PCPs reported ever prescribing nPEP (31.0%), PrEP (18.1%), and ART (27.2%). Prescribing nPEP was associated with nPEP familiarity (aPR = 2.63, 95% CI 1.59, 4.35) and prescribing PrEP (aPR = 3.57, 95% CI 2.78, 4.55). Prescribing PrEP was associated with PrEP familiarity (aPR = 4.35, 95% CI 2.63, 7.14), prescribing nPEP (aPR = 5.00, 95% CI 2.00, 12.50), and providing care for persons with HIV (aPR = 1.56, 95% CI 1.06, 2.27). Prescribing ART was associated with nPEP familiarity (aPR = 1.89, 95% CI 1.27, 2.78) and practicing in outpatient public practice versus hospital-based facilities (aPR = 2.14 95% CI 1.51, 3.04), and inversely associated with collaborations involving specialists (aPR = 0.60, 95% CI 0.42, 0.86). A minority of PCPs surveyed from the Southeast report ever prescribing ARVs for prevention. Future efforts should include enhancing HIV care coordination and developing strategies to increase use of biomedical tools.

Introduction

HIV surveillance data published by the Centers for Disease Control and Prevention (CDC) indicate a trend of reducing HIV incidence in the United States (U.S.) in recent years (Centers for Disease Control and Prevention, 2018a), but disparities remain across various regions and different racial and ethnic groups. Among persons with HIV (PWH) diagnosed in 2017, 52% of all HIV diagnoses occurred in the Southeast U.S., which comprises only 37% of the U.S. population (Centers for Disease Control and Prevention, 2018a). Fifty-three percent of these new diagnoses were made among African Americans, most of whom (80%) were men who have sex with men (MSM) (Centers for Disease Control and Prevention, 2018a). Lack of access to HIV prevention tools contributes to these disparities (Arnold et al., 2017). To reduce HIV incidence, particularly among disproportionately affected populations in the Southeast, public health officials can identify opportunities to improve access to HIV prevention and care tools (Arnold et al., 2017; Elopre et al., 2017).

Antiretrovirals (ARVs) have emerged as potent tools for HIV prevention. For uninfected persons, they can be used as non-occupational post exposure prophylaxis (nPEP) for sexual or injection exposure to HIV (Centers for Disease Control and Prevention, 2005, Centers for Disease Control and Prevention, 2018b). Since receiving approval from the Food and Drug Administration (FDA) in 2012, ARVs have also been used as pre-exposure prophylaxis (PrEP) (Centers for Disease Control and Prevention, 2014) for persons at increased risk of future exposure to HIV. PrEP is an evidence-based HIV prevention strategy that involves taking daily medication to prevent infection via sexual or injection exposure (United States Preventive Services Task Force, 2019). Persons residing in high HIV prevalence areas (which often have elevated rates of poverty) or those reporting recent STI diagnoses likely meet indications for PrEP use (Smith et al., 2018). For PWH, antiretroviral treatment (ART) has been shown to also effectively prevent sexual transmission of the virus to others, a strategy often referred to as treatment as prevention (TasP) (Cohen et al., 2016; Rodger et al., 2016; Bavinton et al., 2018). Despite their proven effectiveness, the extent to which ARVs are used to prevent HIV, particularly among African Americans in the Southeast, remains largely unexamined.

Primary care providers (PCPs), including physicians, nurse practitioners and physician assistants, serve important public health roles in HIV prevention and care (Korthuis et al., 2011; McNaghten et al., 2013). These frontline providers are uniquely positioned to promote the uptake of HIV biomedical interventions, such as use of ARVs for prevention, among underserved populations, including African Americans living in the Southeast (Dorell et al., 2011). The disproportionately low number of HIV clinicians in the region (Gilman et al., 2016) underscores the urgency for engaging PCPs in the uptake of these biomedical prevention interventions.

To address this gap, we examined the associations between prescription practices and selected characteristics among a representative sample of PCPs practicing in six Southeast metropolitan statistical areas (MSAs) with high HIV burden based on national HIV surveillance data. Our specific objectives included (1) assessing the occurrence of nPEP, PrEP and ART prescribing; and (2) identifying sociodemographic, training, practice-level characteristics and other correlates of prescribing these ARVs for prevention.

Section snippets

K-BAP Study

We used a cross sectional study design to examine baseline data from the Knowledge, Behaviors, Attitudes and Practices of HIV-Related Care among Providers in the Southeast (K-BAP) study conducted 2017–2018. This study was reviewed and approved by the Chesapeake Institutional Review Board on June 23, 2016. The United States Government, Office of Management and Budget (OMB # 0920-1160) approved the data collection authorization on February 1, 2017. All procedures for human subjects research were

Results

Of the 7330 providers contacted during survey fielding, we received 995 provider responses, of which 820 were from eligible providers and were included in the analysis. We calculated the survey response rates based on the standards published by the American Association for Public Opinion Research (AAPOR) (The American Association for Public Opinion Research, 2016). The sampling process yielded a raw response rate of 14.9% (AAPOR RR2: excludes known ineligible respondents from denominator;

Discussion

We examined PCPs' practices prescribing ARVs for prevention in high HIV burden areas of the Southeast. Overall, PCPs reported low levels of prescribing nPEP, PrEP and ART: 31.0%, 18.1% and 27.2%, respectively. In comparison to prior reports, our results showed lower frequency of nPEP prescriptions among PCPs (Rodríguez et al., 2013) while our findings related to PrEP were better aligned with previous studies (Tellalian et al., 2013). We also found that relatively few PCPs who cared for PWH

Conclusion

Our study highlights the extent and correlates of nPEP, PrEP and ART prescription among a selection of PCPs in the Southeast. We found that prescription of nPEP and PrEP was relatively low, especially given the region's disproportionate burden of HIV infections. These data together with ART prescribing practices among PCPs highlight an opportunity to expand the reach of HIV prevention and care. In addition, our findings can inform activities to reduce disparities in biomedical prevention tools

Funding

Centers for Disease Control and Prevention (Contract # 200-2015-F-87651).

Declaration of competing interest

None.

Acknowledgments

The findings and conclusions in this report are those of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention (CDC).

Each author contributed to the study design, data analysis, interpretation of the data, and the preparation of manuscript.

Funding for the K-BAP Study is provided by contract # 200-2015-F-87651 from CDC.

No financial disclosures were reported by the authors of manuscript.

We thank the participating K-BAP providers. We also

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