Missed Opportunities for PrEP Prescribing in High-Risk Populations

When pre-exposure prophylaxis (PrEP) is taken consistently, it has been shown to reduce the risk of HIV infection by up to 92%.

PrEP is recommended for individuals who are at a higher risk for HIV, including men who have sex with men (MSM) and drug users. However, a new survey conducted by investigators from the San Francisco Department of Public Health suggests that only 48% of health care providers had ever prescribed PrEP.

The results for the survey were presented last week at the US Centers for Disease Control and Prevention's 2018 National STD Prevention Conference, held in Washington, D.C.

“This brief questionnaire [was key] in evaluating how providers assess sexual risk for HIV and sexually transmitted diseases and their PrEP prescribing practices,” Alyson Decker, NP, MS, MPH, clinical prevention consultant, San Francisco City Clinic, told Contagion^®. “In addition, the survey helps to inform and direct the conversation with providers and measure program outcomes.”

As part of the investigative process, from October 2016 to October 2017, a nurse practitioner visited various practices to provide tailored training on the benefits and use of PrEP to providers with patients that include men who have sex with men (MSM) and trans women. During the session, a survey was conducted. The paper-based, self-report survey was administered to providers by the nurse practitioner.

For their study, the investigators collected a total of 252 surveys from 47 clinician practices. The majority of surveyed participants, 82%, were primary care providers, while 23% were HIV care providers—only 48% of the providers had ever prescribed PrEP. The investigators noted another startling finding—approximately 60% of the participants reported that they do not routinely conduct an annual sexual history with the patients.

Of the 204 providers who reported working with MSM/trans patients, 78, or 38%, reported they do not routinely inquire about receptive anal course with their patients. Additionally, 33%, or 70 of 212 providers, did not screen patients for rectal sexually transmitted diseases, such as gonorrhea and chlamydia.

Factors associated with prescribing PrEP included inquiring about sexual histories regularly (59% vs. 41%, p<0.05), determining receipt of anal intercourse (67% vs. 33%, p<0.05), and screening patients for rectal sexually transmitted diseases (69% vs. 31%, p<0.05).

The findings expose gaps in missed opportunities for sexually transmitted disease screening and PrEP prescribing. “When providers do not routinely talk with patients about their sexual health, then they are unable to identify those who might benefit from these important prevention strategies,” Decker stressed.

As a result of the data, the San Francisco Department of Public Health is launching a follow-up sexual health campaign to increase the frequency of which providers discuss sexual health and test for sexually transmitted diseases in their clinical practice.

Decker, who has been involved in the follow-up campaign, provided insight regarding how similar programs can be created to advocate for sexually transmitted disease screening and PrEP use.

“My advice to other health departments would be to have concise, behavior-based messaging. [You need to] clearly state the action that you are hoping to change instead of just providing facts and figures,” Decker said. “For instance, take a comprehensive sexual history that includes the gender of sexual partners and anatomic sites of sexual exposure during the past year. Limit the campaign to 2 to 4 messages and tailor your materials and detailing around these messages.”