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Many physicians are wary of providing HIV PrEP for young people
Liz Highleyman, 2017-05-22 07:50:00
Only about a
third of family practice and paediatric 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 of 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 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 US 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
colleagues looked at PrEP-related attitudes among
physicians who provide primary care to adolescents. They conducted in-depth
interviews with 38 US physicians from five different specialties – general paediatrics,
family medicine, internal medicine, obstetrics/gynaecology 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 or more difficult 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, the mean age was 45 years and they graduated from medical school an
average of 19 years ago. 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
reduced likelihood of HIV infection (mentioned by 19 providers), acceptability
to patients (13), improved provision of sexual health services (7), improved
patient awareness of their HIV risk (7), effectiveness for HIV prevention (4),
educating patients and communities about HIV and PrEP (4) and improved
adherence to routine daily oral use of PrEP rather than using it at the time of
"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 low cost or coverage by insurance (mentioned
by 19), physician education about PrEP (13), availability of patient
educational materials (11) and clinical guidelines for PrEP use by youth (10).
Perceived barriers to PrEP at the patient
level included lack of acceptability to patients (mentioned by 14), patients
seeing themselves as being at low risk for HIV (8) and the need for regular
Barriers at the physician level included
concerns about patients' adherence and follow-up (mentioned by 30 and 8,
respectively), safety and side-effects concerns (29), parental disapproval
(17), lack of provider education about PrEP (16), lack of FDA approval of PrEP
use by minors (13), concerns about confidentiality (9), concerns about
prescribing to young people (9), not seeing appropriate candidates for PrEP (6)
and lack of legal clarity (6).
System-level barriers included concerns
about cost or lack of insurance coverage (mentioned by 33), logistical barriers
(15), lack of access such as pharmacies refusing to dispense PrEP to young
people (8) and lack of public education and awareness about PrEP and HIV (4).
"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
"If [someone under 18 is] having
really, truly very high risk sexual behaviours, I think that needs a different
level of intervention than 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. Paediatricians 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).
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.