PAS 2017: Many Doctors Wary of Providing PrEP for Young Patients

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Only about a third of family practice and pediatric providers said they would be likely to prescribe HIV pre-exposure prophylaxis (PrEP) to adolescent patients, underlining the need to educate providers outside the HIV and sexually transmitted disease fields, according to a report at the 2017 Pediatric Academic Societies Meeting last week in San Francisco.

Tanya Mullins from Cincinnati Children's Hospital said that clinical guidelines supporting the use of PrEP by adolescents and Food and Drug Administration (FDA) approval of Truvada (tenofovir/emtricitabine) for this age group would also help expand its use.

PrEP is highly effective in preventing HIV transmission when used consistently. The pivotal iPrEx trial of mostly gay and bisexual men showed that daily Truvada reduced the risk of HIV infection by 92% among participants with blood drug levels indicating regular use. Studies have shown that young gay and bi men can do well on PrEP, but they may need extra support to encourage adherence.

The FDA approved Truvada PrEP for adults in July 2012, but it is not yet approved for people under the age of 18. The U.S. Centers for Disease Control and Prevention (CDC) PrEP guidelines state that the drawbacks of PrEP for adolescents -- including the potential for bone loss in youth who are still growing -- should be weighed against the benefit of preventing HIV in adolescents at substantial risk.

Mullins and colleagues looked at PrEP-related attitudes among physicians who provide primary care to adolescents. They conducted in-depth interviews with 38 U.S. physicians from 5 different specialties -- general pediatrics, family medicine, internal medicine, obstetrics/gynecology, and adolescent medicine -- in a large Midwestern metropolitan area who saw at least one patient under age 18 per week.

The interviews assessed familiarity with PrEP, the perceived benefits of and barriers to providing PrEP to adolescents, and factors that would make it easier to offer PrEP. The clinicians were asked how likely they were to recommend PrEP to adolescents, and how likely they were to actually prescribe it.

A majority of the providers (71%) were women, more than 80% were white, the mean age was 45 years, and they graduated from medical school 19 years ago on average. Nearly half had urban practices, half had suburban practices, and just 5% had rural practices. They saw an average of 21 adolescent patients per week.

Most physicians (79%) had previous treated patients with HIV, but only 37% said they were somewhat or very familiar with PrEP.

The perceived benefits of PrEP included:

"I think if someone is taking something every day, it's also sort of a reminder to them maybe about why they're taking it, and trying to be more careful," one respondent said.

The most commonly mentioned facilitating factors for prescribing PrEP were:

Perceived barriers to PrEP at the patient level included:

Barriers at the physician level included:

System-level barriers included:

"I guess I'd consider PrEP [for a patient under age 18] if they're very high risk. But I probably wouldn't do it on a routine basis because it's not recommended for that," one respondent said.

"If [someone under 18 is] having really, truly very high risk sexual behaviors, I think that needs a different level of intervention that me prescribing them [PrEP]," said another.

While 42% of the physicians overall said they were highly or somewhat likely to recommend PrEP, only 34% said they were likely to actually prescribe it.

Pediatricians were the most likely to recommend PrEP, but not to prescribe it (63% and 38%, respectively). Other specialists were equally likely to recommend and prescribe PrEP, including adolescent medicine doctors (50% for both) and ob/gyn providers (38% for both). Internal medicine physicians were least likely to either recommend or prescribe PrEP (17% for both).

"Barriers at multiple levels -- patient, physician, and systems -- need to be addressed," the researchers concluded. Willingness to provide PrEP would be facilitated by further physician education, clinical guidelines specifically supporting PrEP use by adolescents, and FDA approval of PrEP for minors.

5/16/17

Source

TL Mullins, CR Idoine, GD Zimet, et al. Oral Pre-Exposure Prophylaxis (PrEP) for HIV Prevention in Youth: Attitudes of Primary Care Physicians. Pediatric Academic Societies Meeting. San Francisco, May 6-9, 2017. Abstract 2150.5.