Health-care practitioners are split when it comes to opinions on which provider should take the lead in prescribing pre-exposure prophylaxis (PrEP), which is administered to people at high risk for HIV.

That’s according to the findings of a new study by researchers from the University at Buffalo (UB), who interviewed PrEP-prescribing providers to conduct a qualitative analysis of their perspectives on the preventive medication. Their paper was published online ahead of print earlier this month in the Journal of the Association of Nurses in AIDS Care.

In a separate study, UB researchers also surveyed pharmacy students about their knowledge of and views toward the medication. “Understanding barriers and facilitators to PrEP adoption and implementation from both current and future health-care providers is key to accelerate roll-out of this preventive medication to target populations who meet clinical eligibility criteria,” said Sarahmona Przybyla, the study’s lead author. Przybyla is an assistant professor of community health and health behavior in UB’s School of Public Health and Health Professions.

Who should prescribe PrEP?

In the United States, there are more than 1.1 million people living with HIV, and 38,500 new infections occurring annually. It has been 7 years since the US Food and Drug Administration approved PrEP for use in adults, and 1 year for adolescents. Still, previous research has shown that PrEP uptake has not met expectations. For example, the US Centers for Disease Control and Prevention (CDC) estimates that 1.2 million Americans are eligible for the drug, but only 150,000 take it.

PrEP is available only to people who are HIV negative. There’s a debate—dubbed the “purview paradox”—within the health-care and public-health community about who should prescribe PrEP. While HIV specialists are likely to be the most willing and able to prescribe PrEP, they typically don’t see HIV-uninfected patients. Meanwhile, primary care physicians are more likely to see eligible PrEP patients, but generalists may lack the training and skills necessary to prescribe it.

With this in mind, Przybyla and her team surveyed a small sample of clinicians in Erie and Niagara counties in western New York who were licensed to prescribe medication in New York and who had prescribed PrEP for at least 3 months.

Participants were almost equally split on ideal provider type: 15 chose primary care physicians, while 13 said any health-care provider. None of the participants indicated a preference for infectious disease or HIV specialists. That’s likely because there are approximately 8,500 infectious disease specialists in the United States, an insufficient number to treat the 1 million individuals who meet PrEP eligibility guidelines.

Previous studies of patients and health-care providers have shown that primary care physicians are the preferred provider, largely because they’re more available and accessible and because they’re more likely to see patients over a long period of time.

Clinicians are key stakeholders in PrEP engagement for patients at risk of HIV infection, according to Przybyla. “This research provides support for a growing foundation of research that warrants continued efforts to incorporate PrEP into a comprehensive HIV prevention plan at local, state, and national levels.”

Surveying Rx students about PrEP

Przybyla is also the author of the first paper to survey pharmacy students about their knowledge of and attitudes toward PrEP. The study of 291 students enrolled in the pharmacy doctoral program (PharmD) in UB’s School of Pharmacy and Pharmaceutical Sciences found that:

• 89% agreed that PrEP can be a cost-effective tool to prevent HIV infection
• 12% felt that PrEP is too expensive to justify its use
• 16% felt that individuals prescribed the drug would not take it regularly
• 64% felt confident they could counsel patients about PrEP
• 87% reported that they intended to counsel patients about the drug

Other studies have examined PrEP attitudes among pharmacists, physicians, nurse practitioners, and physician assistants, as well as medical students, but none have surveyed pharmacy students, Przybyla said. The study, published online ahead of print in the journal Currents in Pharmacy Teaching and Learning, reveals a need for increased educational efforts to improve pharmacy students’ knowledge of CDC prescription guidelines for the drug.

For example, 40% of respondents—a higher proportion than in previous studies of health-care providers—erroneously believed that widespread use of PrEP could significantly increase rates of antiretroviral resistance. CDC guidelines for clinicians provide detailed evidence that drug-resistant mutations are rare, researchers note.