Provider attitudes toward oral preexposure prophylaxis for HIV prevention among high-risk men who have sex with men in Lima, Peru

Knowledge and attitudes of HIV pre-exposure prophylaxis among nurses in South Africa

BACKGROUND

Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) has shown efficacy and effectiveness in populations who practise high-risk sexual activity. Nurses' knowledge and positive attitudes enhance PrEP implementation.

AIM

This study aimed to investigate the knowledge of and attitudes towards PrEP among nurses in primary health care facilities.

SETTING

The study was conducted in 10 health facilities that offer comprehensive services in Tshwane, South Africa.

METHODS

A cross-sectional survey assessed the knowledge of and attitudes towards PrEP among 114 nurses. Univariate, bivariate and logistic regressions were performed to estimate odds ratios and to determine whether age, sex and education had an association with the knowledge and attitudes.

RESULTS

Majority of the study sample consisted of female nurses (92.1%), and most respondents (68%) had moderate PrEP knowledge. Logistic regression showed that age and education were not associated with high level of knowledge. Pre-exposure prophylaxis was viewed negatively by 84.5% of the respondents. The odds of positive attitudes towards PrEP were 1.92 times higher among males than females (95% CI 0.54-6.83) and 1.24 times higher among nurses who had bachelor's degree than diploma holders (95% CI 0.51-3.01).

CONCLUSION

This study found that there is a need to strengthen the dissemination of information about PrEP, and nurses in South Africa require training to improve their knowledge of and attitudes towards PrEP.Contribution: The findings of the study add to the current knowledge base regarding PrEP access in the public healthcare system and it highlights gaps in the training of healthcare providers.

Health Care Providers as Agents of Change: Integrating PrEP With Other Sexual and Reproductive Health Services for Adolescent Girls and Young Women

Background: Successful integration of pre-exposure prophylaxis (PrEP) with existing reproductive health services will require iterative learning and adaptation. The interaction between the problem-solving required to implement new interventions and health worker motivation has been well-described in the public health literature. This study describes structural and motivational challenges faced by health care providers delivering PrEP to adolescent girls and young women (AGYW) alongside other SRH services, and the strategies used to overcome them. Methods: We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) with HCWs from two demonstration projects delivering PrEP to AGYW alongside other SRH services. The Prevention Options for the Women Evaluation Research (POWER) is an open label PrEP study with a focus on learning about PrEP delivery in Kenyan and South African family planning, youth mobile services, and public clinics at six facilities. PrIYA focused on PrEP delivery to AGYW via maternal and child health (MCH) and family planning (FP) clinics in Kenya across 37 facilities. IDIs and FGDs were transcribed verbatim and analyzed using a combination of inductive and deductive methods. Results: We conducted IDIs with 36 participants and 8 FGDs with 50 participants. HCW described a dynamic process of operationalizing PrEP delivery to better respond to patient needs, including modifying patient flow, pill packaging, and counseling. HCWs believed the biggest challenge to sustained integration and scaling of PrEP for AGYW would be lack of health care worker motivation, primarily due to a misalignment of personal and professional values and expectations. HCWs frequently described concerns of PrEP provision being seen as condoning or promoting unprotected sex among young unmarried, sexually active women. Persuasive techniques used to overcome these reservations included emphasizing the social realities of HIV risk, health care worker professional identities, and vocational commitments to keeping young women healthy. Conclusion: Sustained scale-up of PrEP will require HCWs to value and prioritize its incorporation into daily practice. As with the provision of other SRH services, HCWs may have moral reservations about providing PrEP to AGYW. Strategies that strengthen alignment of HCW personal values with professional goals will be important for strengthening motivation to overcome delivery challenges.

"Now that PrEP is reducing the risk of transmission of HIV, why then do you still insist that we use condoms?" the condom quandary among PrEP users and health care providers in Kenya

Communication around condom use in the context of PrEP services presents a potential conundrum for patients and providers. Within the Partners Scale-Up Project, which supports integration of PrEP delivery in HIV care clinics, we interviewed 41 providers and 61 PrEP users and identified themes relating to condom messaging and use. Most providers counselled PrEP initiators to always use both PrEP and condoms, except when trying to conceive. However, others reported contexts and rationales for not emphasizing condom use. Providers reported that PrEP users were sometimes confused, even frustrated, with their insistence on using condoms in addition to PrEP. PrEP users generally regarded PrEP as a more feasible and desirable HIV prevention method than condoms, enabling increased sexual pleasure and conception, and reducing the conflict and stigma associated with condom use. Innovative approaches to condom counselling in PrEP programs are needed.

[Care providers' knowledge and willingness to prescribe pre-exposure prophylaxis (PrEP) in Kinshasa, Democratic Republic of Congo (DRC)]

Introduction

la réduction de l'incidence de nouvelles infections liées au VIH est un objectif de santé publique. L’objectif de l’étude était d’évaluer la connaissance et volonté de prescrire la PrEP à Kinshasa.

Méthodes

il s’agit d’une étude transversale à visée analytique auprès des prestataires de soins de 4 structures de prise en charge de VIH/SIDA de la ville de Kinshasa d’avril à octobre 2017. Les analyses univariées et multivariées par régression logistique ont été effectuées pour identifier les facteurs associés à la connaissance et la volonté de prescrire la PrEP.

Résultats

quatre-vingt-cinq prestataires ont répondu à l’enquête. Moins du quart des prestataires connaissaient la PrEP avant l’enquête et la moitié avait la volonté de la prescrire. La barrière à cet acte évoquée était la résistance (83%). Les facteurs associés à la connaissance de la PrEP étaient la spécialité d’infectiologie et l’expertise en VIH. Les facteurs associés à la volonté de prescrire la PrEP étaient l’âge supérieur à 40 ans, la spécialité d’infectiologie et l’expertise en VIH.

Conclusion

la connaissance de la PrEP à Kinshasa était faible et seule la moitié des prestataires était disposée à la prescrire. Etre médecin infectiologue et expert en VIH était associé à la connaissance et la volonté de prescrire. Les futurs programmes d'éducation devraient renforcer la connaissance sur la PrEP et aborder les préoccupations identifiées dont les barrières à la prescription.

Physicians' preparedness for pre-exposure prophylaxis: results of an online survey in Belgium

Background Physicians have a crucial role in the implementation and scale up of pre-exposure prophylaxis (PrEP). The objective of this study is to examine Belgian physicians' PrEP knowledge, concerns, acceptance and their willingness to prescribe PrEP.

METHODS

A cross-sectional online survey was conducted between March and June 2016. Dissemination targeted Belgian primary care physicians (PCPs) and HIV specialists. Sociodemographic characteristics, experience with HIV and PrEP, self-assessed PrEP knowledge, concerns about PrEP, and PrEP acceptance were stratified according to professional background. Associations with willingness to prescribe PrEP were examined using univariable and multivariable binary logistic regression analyses.

RESULTS

In total, 333 completed surveys were included in the analysis. Sixty-two physicians (18.6%) scored their knowledge of PrEP to be good, 263 (79.0%) had an accepting attitude towards PrEP and 198 (59.5%) were willing to prescribe PrEP if approved in Belgium. HIV specialists consistently reported having better knowledge of PrEP, less concerns and a more accepting attitude towards PrEP than PCPs. In multivariable logistic regression analysis, higher PrEP knowledge (OR 2.4; 95%CI: 1.0-5.7) and higher PrEP acceptance (OR: 3.8; 95%CI: 2.1-6.8) remained significantly associated with the willingness to prescribe PrEP.

CONCLUSIONS

HIV specialists are better prepared to provide PrEP than PCPs in Belgium. Interventions to improve PrEP knowledge and acceptance among all providers are needed. The role of PCPs could be very important in optimising the rollout of PrEP, but additional training and guidelines will be needed.

The stratified biomedicalization of HIV prevention in Mexico City

In the late 1990s antiretroviral pharmaceuticals began to be used in the United States and Western Europe to prevent HIV infection in contexts of occupational exposure. One decade later, the application of Post Exposure Prophylaxis (PEP) and Pre-Exposure Prophylaxis (PrEP) had been extended to include cases of exposure to sexual assault, injection-drug use, and consensual sexual intercourse deemed at high risk. This article explores the implementation of biomedicalized HIV prevention protocols at a public healthcare clinic in Mexico City, building on sociological-feminist approaches in Science and Technology Studies (STS) and drawing on interviews with key actors, as well as digital ethnography. We emphasise the stratified biomedicalization or, said otherwise, the differences in PEP and PrEP accessibility and consumption among different populations and groups. We also describe the fragile grip of institutionalised biomedical solutions when alternative 'moral economies' intersect with them, particularly in contexts like Mexico, where governmental funding for experimental research on biomedical innovations has been limited. This text reveals both the existence of contrasting technoscientific interventions along class and gender differences, and the multiple and vivid ways by which individuals appropriate and interpret global biomedical practices.

A Cross-sectional Survey of Internal Medicine Resident Knowledge, Attitudes, Behaviors, and Experiences Regarding Pre-Exposure Prophylaxis for HIV Infection

BACKGROUND

Pre-exposure prophylaxis (PrEP) for HIV is effective, yet many providers continue to lack knowledge and comfort in providing this intervention. It remains unclear whether internal medicine (IM) residents receive appropriate training in PrEP care and if this affects their future practices.

OBJECTIVE

We sought to evaluate the relationship between current IM residents' prior PrEP training and knowledge, comfort, and practice regarding the provision of PrEP.

DESIGN AND PARTICIPANTS

We created an online survey to assess IM residents' knowledge, attitudes, and behaviors related to PrEP. The survey was distributed among five IM programs across the USA.

KEY RESULTS

We had a 35% response rate. Of 229 respondents, 96% (n = 220) had heard of PrEP but only 25% (n = 51) had received prior training and 11% (n = 24) had prescribed PrEP. Compared with those without, those with prior training reported good to excellent knowledge scores regarding PrEP (80% versus 33%, p < 0.001), more frequent prescribing (28% versus 7%, p = 0.001), and higher comfort levels with evaluating risk for HIV, educating patients, and monitoring aspects of PrEP (75% versus 26%, 56% versus 16%, and 47% versus 8%, respectively; all p values < 0.0001). While only 25% (n = 51) had received prior training, 75% (n = 103) of respondents reported that training all providers at their continuity clinic sites would improve implementation.

CONCLUSIONS

We found that prior training was associated with higher levels of self-reported PrEP knowledge, comfort, and prescribing behaviors. Given the significant need for PrEP, IM residents should be trained to achieve adequate knowledge and comfort levels to prescribe it. This study demonstrates that providing appropriate PrEP training for IM residents may lead to an increase in the pool of graduating IM residents prescribing PrEP.

Healthcare providers' knowledge, readiness, prescribing behaviors, and perceived barriers regarding routine HIV testing and pre-exposure prophylaxis in DeLand, Florida

Objectives

Florida ranks highest in the United States among newly diagnosed HIV infections. This ranking reflects the need for investigation of healthcare providers' knowledge, readiness, prescribing behaviors, and perceived barriers to routine HIV testing and pre-exposure prophylaxis.

Methods

We adapted national questionnaires with questions co-developed with Florida Department of Health to form a 25-item instrument. Questionnaires were distributed to the population of eligible healthcare providers in DeLand, Florida.

Results

Results from an approximate 20% response rate that encompasses 12 providers demonstrate baseline findings to inform future studies. For example, 75% of respondents were aware of FL Administrative Code 64D-3.042 that pregnant women should receive HIV testing during first and third trimesters. However, 50% of respondents rarely or never offer tests to pregnant women according to practice guidelines. About 75% of respondents strongly agree or agree with willingness to prescribe pre-exposure prophylaxis to high-risk patients, yet 8.3% always or very often prescribe pre-exposure prophylaxis.

Conclusions

Results convey the importance of and need for greater collaboration between providers and the Florida Department of Health to enhance providers' knowledge, readiness, and, ultimately, behaviors regarding routine HIV testing and pre-exposure prophylaxis prescription.

Provider perspectives on PrEP for adolescent girls and young women in Tanzania: The role of provider biases and quality of care

BACKGROUND

Oral pre-exposure prophylaxis (PrEP) has the potential to reduce HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa. However, health care providers' (HCPs) perspectives and interactions with potential clients can substantially influence effective provision of quality health services. We examine if HCPs' knowledge, attitude, and skills, as well as their perceptions of facility readiness to provide PrEP are associated with their willingness to provide PrEP to AGYW at high risk of HIV in Tanzania.

METHODS

A self-administered questionnaire was given to 316 HCPs from 74 clinics in two districts and 24 HCPs participated in follow-up in-depth interviews (IDIs). We conducted bivariate and multivariable Poisson regression to assess factors associated with willingness to provide PrEP to AGYW. Thematic content analysis was used to analyze the IDIs, which expanded upon the quantitative results.

RESULTS

Few HCPs (3.5%) had prior PrEP knowledge, but once informed, 61.1% were willing to prescribe PrEP to AGYW. Higher negative attitudes toward adolescent sexuality and greater concerns about behavioral disinhibition due to PrEP use were associated with lower willingness to prescribe PrEP. Qualitatively, HCPs acknowledged that biases, rooted in cultural norms, often result in stigmatizing and discriminatory care toward AGYW, a potential barrier for PrEP provision. However, better training to provide HIV services was associated with greater willingness to prescribe PrEP. Conversely, HCPs feared the potential negative impact of PrEP on the provision of existing HIV services (e.g., overburdened staff), and suggested the integration of PrEP into non-HIV services and the use of paramedical professionals to facilitate PrEP provision.

CONCLUSIONS

Preparing for PrEP introduction requires more than solely training HCPs on the clinical aspects of providing PrEP. It requires a two-pronged strategy: addressing HCPs' biases regarding sexual health services to AGYW; and preparing the health system infrastructure for the introduction of PrEP.

Preexposure Prophylaxis of HIV Infection: the Role of Clinical Practices in Ending the HIV Epidemic

PURPOSE OF REVIEW

The aim of this study is to summarise the recent evidence from high-income settings about providers' ability to deliver on the UNAIDS goal of at least three million people at substantial risk of HIV infection with PrEP by 2020, including awareness and knowledge about PrEP, willingness to prescribe PrEP, current levels of prescribing and service delivery models and issues.

RECENT FINDINGS

Awareness about PrEP among health providers is growing, but at different pace depending on provider type. HIV and sexual health specialists are more likely to have knowledge about PrEP than generalists, and to be willing to prescribe it, mainly because of their closer contact with people at high risk for HIV and better risk assessment skills. There is still no consensus as to who should be responsible for providing PrEP, but clearly all hands on deck will be useful in delivering on the international target of three million people at substantial risk for HIV on PrEP by 2020. Only about 5% of the target has been reached so far. Local guidance and large-scale education and information programs for clinicians will be necessary to upskill health providers. High cost of PrEP is still a major barrier for its broad implementation, even in countries were PrEP roll-out has started. Health services are facing major structural challenges due to implementation of PrEP services to a substantial volume of patients. The early implementation experiences demonstrated that PrEP can be successfully delivered across a variety of settings, and a broad range of strategies and models of care can streamline PrEP delivery. Education of the providers and PrEP cost solutions will be essential for rapid roll-out of PrEP.

Values and Preferences on the Use of Oral Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Multiple Populations: A Systematic Review of the Literature

Daily oral pre-exposure prophylaxis (PrEP) is the use of antiretroviral drugs by HIV-negative people to prevent HIV infection. WHO released new guidelines in 2015 recommending PrEP for all populations at substantial risk of HIV infection. To prepare these guidelines, we conducted a systematic review of values and preferences among populations that might benefit from PrEP, women, heterosexual men, young women and adolescent girls, female sex workers, serodiscordant couples, transgender people and people who inject drugs, and among healthcare providers who may prescribe PrEP. A comprehensive search strategy reviewed three electronic databases of articles and HIV-related conference abstracts (January 1990-April 2015). Data abstraction used standardised forms to categorise by population groups and relevant themes. Of 3068 citations screened, 76 peer-reviewed articles and 28 conference abstracts were included. Geographic coverage was global. Most studies (N = 78) evaluated hypothetical use of PrEP, while 26 studies included individuals who actually took PrEP or placebo. Awareness of PrEP was low, but once participants were presented with information about PrEP, the majority said they would consider using it. Concerns about safety, side effects, cost and effectiveness were the most frequently cited barriers to use. There was little indication of risk compensation. Healthcare providers would consider prescribing PrEP, but need more information before doing so. Findings from a rapidly expanding evidence base suggest that the majority of populations most likely to benefit from PrEP feel positively towards it. These same populations would benefit from overcoming current implementation challenges with the shortest possible delay.

Awareness and attitudes of pre-exposure prophylaxis for HIV prevention among physicians in Guatemala: Implications for country-wide implementation

INTRODUCTION

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.

A Cross-Sectional Online Survey of HIV Pre-Exposure Prophylaxis Adoption Among Primary Care Physicians

BACKGROUND

Among health care providers, prescription of HIV pre-exposure prophylaxis (PrEP) has been low. Little is known specifically about primary care physicians (PCPs) with regard to PrEP awareness and adoption (i.e., prescription or referral), and factors associated with adoption.

OBJECTIVE

To assess PrEP awareness, PrEP adoption, and factors associated with adoption among PCPs.

DESIGN

Cross-sectional online survey conducted in April and May 2015.

RESPONDENTS

Members of a national professional organization for academic primary care physicians (n = 266).

MAIN MEASURES

PrEP awareness, PrEP adoption (ever prescribed or referred a patient for PrEP [yes/no]), provider and practice characteristics, and self-rated knowledge, attitudes, and beliefs associated with adoption.

KEY RESULTS

The survey response rate was 8.6 % (266/2093). Ninety-three percent of respondents reported prior awareness of PrEP. Of these, 34.9 % reported PrEP adoption. In multivariable analysis of provider and practice characteristics, compared with non-adopters, adopters were more likely to provide care to more than 50 HIV-positive patients (vs. 0, aOR = 6.82, 95 % CI 2.06-22.52). Compared with non-adopters, adopters were also more likely to report excellent, very good, or good self-rated PrEP knowledge (15.1 %, 33.7 %, 30.2 % vs. 2.5 %, 18.1 %, 23.8 %, respectively; p < 0.001) and to perceive PrEP as extremely safe (35.1 % vs. 10.7 %; p = 0.002). Compared with non-adopters, adopters were less likely to perceive PrEP as being moderately likely to increase risk behaviors ("risk compensation") (12.8 % vs. 28.8 %, p = 0.02).

CONCLUSIONS

While most respondents were aware of PrEP, only one-third of PrEP-aware PCPs reported adoption. Adopters were more likely to have experience providing HIV care and to perceive PrEP as extremely safe, and were less likely to perceive PrEP use as leading to risk compensation. To enhance PCP adoption of PrEP, educational efforts targeting PCPs without HIV care experience should be considered, as well as training those with HIV care experience to be PrEP "clinical champions". Concerns about safety and risk compensation must also be addressed.

Towards a fair consideration of PrEP as part of combination HIV prevention in Latin America

INTRODUCTION

Despite progress in scaling up antiretroviral treatment, HIV prevention strategies have not been successful in significantly curbing HIV incidence in Latin America. HIV prevention interventions need to be expanded to target the most affected key populations with a combination approach, including new high impact technologies. Oral pre-exposure prophylaxis (PrEP) is recommended as additional prevention choice for individuals at higher risk of infection and could become a cost-effective prevention tool. We discuss the barriers and solutions for a fair consideration of PrEP as part of combination HIV prevention strategies in Latin America.

DISCUSSION

Although demonstration projects are ongoing or being planned in a number of countries, to date no Latin American country has implemented a public PrEP programme. The knowledge of policymakers about PrEP implementation needs to be strengthened, and programmatic guidance and cost estimate tools need to be developed to support adequate planning. Despite high levels of awareness among health providers, especially if engaged in HIV or key population care, willingness to prescribe PrEP is still low due to the lack of national policies and guidelines. Key populations, especially men who have sex with men, transgender women and sex workers, have been engaged in demonstration projects, and qualitative research shows high awareness and willingness to use PrEP, especially if accessible in the public sector for free or at affordable price. Concerns of safety, adherence, effectiveness and risk compensation need to be addressed through targeted social communication strategies to improve PrEP knowledge and stimulate demand. Alliance among policymakers, civil society and representatives from key populations, healthcare providers and researchers will be critical for the design and successful implementation of PrEP demonstration projects of locally adapted delivery models. The use of mechanisms of joint negotiation and procurement of antiretrovirals could reduce costs and significantly increase the cost-effectiveness of PrEP.

CONCLUSIONS

PrEP is an additional prevention tool and should be implemented in combination and synergy with other prevention interventions. PrEP programmes should target high-risk individuals from key populations for higher cost-effectiveness. Demonstration projects may generate strategic information for and lead to the implementation of full-scale PrEP programmes.

The role of healthcare providers in the roll out of preexposure prophylaxis

PURPOSE OF REVIEW

To review the most recent studies assessing the preparedness of healthcare practitioners to provide anti-HIV preexposure prophylaxis (PrEP) and suggest areas for future implementation research.

RECENT FINDINGS

As PrEP is a biobehavioral intervention, healthcare providers are likely to play a critical role in implementing PrEP in care settings. Studies suggest that many specialized providers are aware of PrEP and support its provision as a public health intervention, though knowledge and acceptance are less among generalists. Therefore, utilization of PrEP by clinicians has been limited to a few early adopters. Concerns about the efficacy and long-term safety of PrEP, and perceived barriers to prescribing PrEP, could limit prescribing behaviors and intentions. Resistance to performing routine HIV risk assessments by clinicians is an additional barrier to implementing PrEP, although innovative tools to help clinicians routinely perform risk assessments, are being developed.

SUMMARY

Interventions are needed to engage a broader array of healthcare providers in PrEP provision. Utilizing a framework based on diffusion of innovation theory, this review proposes strategies that can be implemented and evaluated to increase PrEP prescribing by healthcare providers. If resources are invested in training clinicians to provide PrEP, then these stakeholders could enhance the use of PrEP as part of a prevention package by primary providers.

Community Federally Qualified Health Centers as Homes for HIV Preexposure Prophylaxis: Perspectives from South Florida

Preexposure prophylaxis (PrEP) for HIV has the potential to reduce HIV incidence in highly affected areas. The Southeastern United States is disproportionately impacted by HIV, and 3 counties in South Florida have the highest incidence of new HIV infections in the United States. This study explored the feasibility, acceptability, and uptake of PrEP in South Florida. Focus groups consisting of providers, administrators, and case managers at HIV-servicing community health centers and federally qualified health centers in South Florida reported broad support but low implementation of PrEP. Generally, participants indicated that the centers were appropriate locations for implementation. However, practical concerns and perceived limitations due to financial, insurance, and immigration status of those who would potentially benefit from the intervention were widely reported. Addressing provider concerns appears necessary for successful expansion of PrEP implementation in highly impacted areas such as South Florida.

Understanding HIV Care Provider Attitudes Regarding Intentions to Prescribe PrEP

INTRODUCTION

Preexposure prophylaxis (PrEP) is a promising approach to reducing HIV incidence. So, garnering the support of HIV providers, who are most familiar with antiretrovirals and likely to encounter patients in HIV serodiscordant relationships, to scale-up PrEP implementation is essential. We sought to determine whether certain subgroups of HIV providers were more likely to intend to prescribe PrEP.

METHODS

Surveys were administered to HIV providers in Miami, Florida and Washington, District of Columbia. Composite scores were developed to measure PrEP knowledge, experience, and likelihood of prescribing. Latent class analysis was used to stratify provider attitudes toward PrEP.

RESULTS

Among 142 HIV providers, 73.2% had cared for more than 20 HIV-infected patients in the previous 3 months; 17% had ever prescribed PrEP. Latent class analysis identified 2 classes of providers (entropy, 0.904); class 1 (n = 95) found PrEP less effective and perceived barriers to prescribing it; class 2 (n = 47) perceived PrEP as moderately effective and perceived fewer barriers to prescribing it. Compared with class 2, class 1 had significantly less experience with PrEP delivery (t(22.7) = 2.88, P = 0.009) and was significantly less likely to intend to prescribe to patients with multiple sex partners (20% vs. 43%, P = 0.04) and those with a drug use history (7% vs. 24%, P = 0.001).

CONCLUSIONS

Although most HIV providers found PrEP to be effective, those considering it less effective had limited knowledge and experience with PrEP and had lesser intentions to prescribe. Provider training regarding whom should receive PrEP and addressing potential barriers to PrEP provision are needed if this HIV prevention method is to be optimized.

How Stigma Surrounding the Use of HIV Preexposure Prophylaxis Undermines Prevention and Pleasure: A Call to Destigmatize "Truvada Whores"

Antiretroviral preexposure prophylaxis (PrEP; emtricitabine and tenofovir disoproxil fumarate [Truvada]) prevents HIV without penalizing sexual pleasure, and may even enhance pleasure (e.g., by reducing HIV-related anxiety). However, concern about sexual risk behavior increasing with PrEP use (risk compensation) and corresponding stereotypes of promiscuity may undermine PrEP's preventive potential. In this commentary, we review literature on sexual behavior change accompanying PrEP use, discuss risk compensation concerns and the "Truvada whore" stereotype as PrEP barriers, question the appropriateness of restricting PrEP access because of risk compensation, and consider sexual pleasure as a benefit of PrEP, an acceptable motive for seeking PrEP, and a core element of health. It is essential for science to trump stereotypes and sex-negative messaging in guiding decision-making affecting PrEP access and uptake.

Knowledge, Beliefs and Practices Regarding Antiretroviral Medications for HIV Prevention: Results from a Survey of Healthcare Providers in New England

Background

Antiretroviral treatment for HIV-infection before immunologic decline (early ART) and pre-exposure chemoprophylaxis (PrEP) can prevent HIV transmission, but routine adoption of these practices by clinicians has been limited.

Methods

Between September and December 2013, healthcare practitioners affiliated with a regional AIDS Education and Training Center in New England were invited to complete online surveys assessing knowledge, beliefs and practices regarding early ART and PrEP. Multivariable models were utilized to determine characteristics associated with prescribing intentions and practices.

Results

Surveys were completed by 184 practitioners. Respondent median age was 44 years, 58% were female, and 82% were white. Among ART-prescribing clinicians (61% of the entire sample), 64% were aware that HIV treatment guidelines from the Department of Health and Human Services recommended early ART, and 69% indicated they would prescribe ART to all HIV-infected patients irrespective of immunologic status. However, 77% of ART-prescribing clinicians would defer ART for patients not ready to initiate treatment. Three-fourths of all respondents were aware of guidance from the U.S. Centers for Disease Control and Prevention recommending PrEP provision, 19% had prescribed PrEP, and 58% of clinicians who had not prescribed PrEP anticipated future prescribing. Practitioners expressed theoretical concerns and perceived practical barriers to prescribing early ART and PrEP. Clinicians with higher percentages of HIV-infected patients (aOR 1.16 per 10% increase in proportion of patients with HIV-infection, 95% CI 1.01–1.34) and infectious diseases specialists (versus primary care physicians; aOR 3.32, 95% CI 0.98–11.2) were more likely to report intentions to prescribe early ART. Higher percentage of HIV-infected patients was also associated with having prescribed PrEP (aOR 1.19, 95% CI 1.06–1.34), whereas female gender (aOR 0.26, 95% CI 0.10–0.71) was associated with having not prescribed PrEP.

Conclusions

These findings suggest many clinicians have shifted towards routinely recommending early ART, but not PrEP, so interventions to facilitate PrEP provision are needed.

Client and provider perspectives on new HIV prevention tools for MSM in the Americas

Men who have sex with men (MSM) in the Americas require targeted, combination HIV prevention approaches. We solicited client and provider perspectives on emerging prevention interventions including HIV pre-exposure prophylaxis (PrEP) and HIV self-tests through focus groups and in-depth interviews with 130 MSM and 41 providers across four sites: New York, San Francisco, Lima, and Rio de Janeiro. Among the MSM participants, we identified three prevention typologies: non-condom users, inconsistent condom users, and consistent condom users. Northern and Southern MSM differed in the variety of harm reduction strategies utilized: where U.S. MSM relied on condom use as well as disclosure and seroadaptive behaviors for prevention, condom use without disclosure or serostatus discussions was the norm in South America. Interest in new prevention technologies was shaped by the social context. U.S. MSM preferences differed by typology, such that non-condom users were interested in taking PrEP and using home HIV tests. MSM in Brazil, regardless of typology, were interested in exploring new prevention options. MSM in Peru demonstrated moderate interest but were less comfortable with adopting new strategies. MSM and providers' opinions differed substantially with respect to new prevention options. Across sites, most providers were reticent to engage with new prevention options, though some NGO-based providers were more supportive of exploring new prevention tools. Both clients and providers will need to be engaged in developing integrated prevention strategies for MSM.