title: Awareness and attitudes of pre-exposure prophylaxis for HIV prevention among physicians in Guatemala: Implications for country-wide implementation.
abstract: BACKGROUND
  HIV continues to be a major health concern with approximately 2.1 million new infections occurring worldwide in 2015. In Central America, Guatemala had the highest incident number of HIV infections (3,700) in 2015. Antiretroviral pre-exposure prophylaxis (PrEP) was recently recommended by the World Health Organization (WHO) as an efficacious intervention to prevent HIV transmission. PrEP implementation efforts are underway in Guatemala and success will require providers that are knowledgeable and willing to prescribe PrEP. We sought to explore current PrEP awareness and prescribing attitudes among Guatemalan physicians in order to inform future PrEP implementation efforts.
  
  
  METHODS
  We conducted a cross-sectional survey of adult internal medicine physicians at the main teaching hospital in Guatemala City in March 2015. The survey included demographics, medical specialty, years of HIV patient care, PrEP awareness, willingness to prescribe PrEP, previous experience with post-exposure prophylaxis, and concerns about PrEP. The primary outcome was willingness to prescribe PrEP, which was assessed using a 5-point Likert scale for different at-risk population scenarios. Univariate and multivariate logistic regression was performed to identify predictors for willingness to prescribe PrEP.
  
  
  RESULTS
  Eighty-seven physicians completed the survey; 66% were male, 64% were internal medicine residency trainees, and 10% were infectious disease (ID) specialists. Sixty-nine percent of physicians were PrEP aware, of which 9% had previously prescribed PrEP. Most (87%) of respondents were willing to prescribe PrEP to men who have sex with men (MSM), sex workers, injection drug users, or HIV-uninfected persons having known HIV-positive sexual partners. Concerns regarding PrEP included development of resistance (92%), risk compensation (90%), and cost (64%). Univariate logistic regression showed that younger age, being a resident trainee, and being a non-ID specialist were significant predictors for willingness to prescribe PrEP. In multivariate logistic regression, being a non-ID specialist was a significant predictor.
  
  
  CONCLUSIONS
  Guatemalan physicians at an urban public hospital were PrEP aware and willing to prescribe, but few have actually done so yet. Future education programs should address the concerns identified, including the low potential for the development of antiretroviral resistance. These findings can aid PrEP implementation efforts in Guatemala.
authors.affiliation: Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America.
authors.forename: Ian
authors.initials: I
authors.lastname: Ross
authors.affiliation: Division of Infectious Diseases, Roosevelt Hospital, Guatemala City, Guatemala.
authors.forename: Carlos
authors.initials: C
authors.lastname: Mejia
authors.affiliation: Division of Infectious Diseases, Roosevelt Hospital, Guatemala City, Guatemala.
authors.forename: Johanna
authors.initials: J
authors.lastname: Melendez
authors.affiliation: Division of Infectious Diseases, Brown University, Providence, Rhode Island, United States of America.
authors.forename: Philip A
authors.initials: PA
authors.lastname: Chan
authors.affiliation: Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, United States of America.
authors.forename: Amy C
authors.initials: AC
authors.lastname: Nunn
authors.affiliation: Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America.
authors.forename: William
authors.initials: W
authors.lastname: Powderly
authors.affiliation: Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America.
authors.forename: Katherine
authors.initials: K
authors.lastname: Goodenberger
authors.affiliation: Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri, United States of America.
authors.forename: Jingxia
authors.initials: J
authors.lastname: Liu
authors.affiliation: Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America.|Division of Infectious Diseases, Harvard Medical School, Boston, Massachusetts, United States of America.|The Fenway Institute, Fenway Health, Boston, Massachusetts, United States of America.
authors.forename: Kenneth H
authors.initials: KH
authors.lastname: Mayer
authors.affiliation: Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America.
authors.forename: Rupa R
authors.initials: RR
authors.lastname: Patel
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D001291:Attitude of Health Personnel; D003430:Cross-Sectional Studies; D005260:Female; D006166:Guatemala; D015658:HIV Infections / Q000517:prevention & control*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010820:Physicians / Q000523:psychology; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D065129:Pre-Exposure Prophylaxis / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires
chemical_list: D019380:Anti-HIV Agents