Are Patients Responsible for Initiating Conversations About PrEP?

It has been demonstrated that pre-exposure prophylaxis (PrEP) is efficacious in preventing HIV and recent efforts have focused on increasing uptake among ideal candidates.

In a new investigation, published in the Journal of General Internal Medicine, a team of investigators set out to study barriers that may affect patients seeking a PrEP prescription in Veterans Health Administration (VHA) settings.

One common barrier to PrEP uptake is the high price tag, but in the VHA setting there are fewer cost barriers than there are associated with commercial insurance. Therefore, the investigators set out to evaluate other barriers that may inhibit PrEP uptake.

In order to do so, the investigators extracted descriptive information from electronic medical records and conducted a qualitative analysis of all PrEP-relevant notes. The team collected information including whether the PrEP conversation was provider or patient-initiated, time to interval between request and prescription, reasons for PrEP denial, and patient responses to barriers. Information was collected from 161 patients who were prescribed PrEP at 90 VHA sites, with varying PrEP prescribing rates.

“Although this particular analysis was conducted with a VHA data set, we know from CDC [US Centers for Disease Control and Prevention] estimates that PrEP uptake is low across settings, so it's likely that the barriers we identified are not limited to VHA,” Avy Skolnik, PhD, staff psychologist, University Health Services, UMass Amherst, and an author on the article told Contagion®. “Unnecessary delays (delays not due to a medical contraindication, for example) most commonly resulted from providers being either unfamiliar with PrEP, or unfamiliar with systems or processes in place for initiating PrEP.”

The investigators found that patients initiated 94% of PrEP conversations. Additionally, 35% of patients experienced delays in receiving PrEP, which ranged from 6 weeks to 16 months.

“It was striking that in 90% of the cases we reviewed, patients, not providers, initiated the conversation about HIV risk and PrEP,” Skolnik said. “Furthermore, many patients had to inquire about PrEP multiple times after being refused.”

In addition, 35% of the cases analyzed had evidence of barriers to access. Barriers included knowledge gaps about PrEP and VHA systems related to PrEP, and confusion or disagreement over clinic purview for PrEP.

“I think that this finding, along with attitudinal barriers we identified, highlights the fact that the stigma about HIV and bias towards communities we associate with HIV at least partially explain why PrEP uptake is low both within and outside of VHA,” Skolnik continued.

According to the report, current practices place substantial responsibility on patients to request PrEP for HIV prevention and advocate for this service, in contrast to many other preventive services.

The investigators also report that some of the delays were associated with the “purview paradox” during which providers are unsure about whether PrEP initiation and maintenance belong in primary or specialty care.

“Clearly establishing the location of care and communicating this to providers across specialties would help address this issue at the facilities in which this clinic purview barrier was apparent,” Skolnik told Contagion®.

Skolnik also said that in order to improve PrEP update it’s important to improve candidate identification.

“Providers who can ask proactively and sensitively about their patient's safer sex practices and substance use are in a good position to identify PrEP candidates, especially when providers have a good relationship with their patients,” he said. “This is especially important, since most people need to feel some trust with their provider in order to disclose personal information that could make them vulnerable to experiencing stigma, judgement, or discrimination.”

Despite the high rate of barriers and delays reflecting a need for improvement, Skolnik concludes that overall the VHA has many providers who are doing a great job in providing access to PrEP.

“There were also many examples of both timely access and quality care throughout the PrEP initiation process. So, while there may be room for improvement, there are many VHA facilities and providers doing excellent HIV preventative care, including utilizing PrEP when indicated.”