Putting PrEP into Practice: Lessons Learned from Early-Adopting U.S. Providers' Firsthand Experiences Providing HIV Pre-Exposure Prophylaxis and Associated Care.
Optimizing access to HIV pre-exposure prophylaxis (PrEP), an evidence-based HIV prevention resource, requires expanding healthcare providers' adoption of PrEP into clinical practice. This qualitative study explored PrEP providers' firsthand experiences relative to six commonly-cited barriers to prescription-financial coverage, implementation logistics, eligibility determination, adherence concerns, side effects, and anticipated behavior change (risk compensation)-as well as their recommendations for training PrEP-inexperienced providers. U.S.-based PrEP providers were recruited via direct outreach and referral from colleagues and other participants (2014-2015). One-on-one interviews were conducted in person or by phone, transcribed, and analyzed. The sample (n = 18) primarily practiced in the Northeastern (67%) or Southern (22%) U.S. Nearly all (94%) were medical doctors (MDs), most of whom self-identified as infectious disease specialists. Prior experience prescribing PrEP ranged from 2 to 325 patients. Overall, providers reported favorable experiences with PrEP implementation and indicated that commonly anticipated problems were minimal or manageable. PrEP was covered via insurance or other programs for most patients; however, pre-authorization requirements, laboratory/service provision costs, and high deductibles sometimes presented challenges. Various models of PrEP care and coordination with other providers were utilized, with several providers highlighting the value of clinical staff support. Eligibility was determined through joint decision-making with patients; CDC guidelines were commonly referenced but not considered absolute. Patient adherence was variable, with particularly strong adherence noted among patients who had actively sought PrEP (self-referred). Providers observed minimal adverse effects or increases in risk behavior. However, they identified several barriers with respect to accessing and engaging PrEP candidates. Providers offered a wide range of suggestions regarding content, strategy, and logistics surrounding PrEP training, highlighting sexual history-taking and sexual minority competence as areas to prioritize. These insights from early-adopting PrEP providers may facilitate adoption of PrEP into clinical practice by PrEP-inexperienced providers, thereby improving access for individuals at risk for HIV.
Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, CT, United States of America.|Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States of America.
Sarah K
SK
Calabrese
Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, Washington, DC, United States of America.
Manya
M
Magnus
The Fenway Institute, Fenway Health, Boston, MA, United States of America.|Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America.
Kenneth H
KH
Mayer
The Fenway Institute, Fenway Health, Boston, MA, United States of America.|Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America.
Douglas S
DS
Krakower
Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, CT, United States of America.
Adam I
AI
Eldahan
Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, CT, United States of America.
Lauren A
LA
Gaston Hawkins
Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States of America.|Department of Health Promotion and Behavior, College of Public Health, University of Georgia, Athens, GA, United States of America.
Nathan B
NB
Hansen
Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, CT, United States of America.|Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States of America.
Trace S
TS
Kershaw
Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States of America.|Yale Law School, Yale University, New Haven, CT, United States of America.
Kristen
K
Underhill
Disparities Solutions Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
Joseph R
JR
Betancourt
Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, CT, United States of America.|Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States of America.|Department of Psychology, Yale University, New Haven, CT, United States of America.
John F
JF
Dovidio
D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D005260:Female; D015658:HIV Infections / Q000517:prevention & control* / Q000628:therapy; D006282:Health Personnel / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D065129:Pre-Exposure Prophylaxis / Q000379:methods*; D011315:Preventive Medicine / Q000379:methods / Q000706:statistics & numerical data; D015203:Reproducibility of Results; D011795:Surveys and Questionnaires; D014481:United States
D019380:Anti-HIV Agents