Attitude Towards ART PrEP Prescription Among HIV Specialists
Attitude Towards ART PrEP Prescription Among HIV Specialists
Most focus group participants reported a "not detailed" knowledge about the results of published PrEP trials, and expressed concerns regarding PrEP use. The main concerns that emerged were: duration of use, side effects and long term toxicities; ARV resistance; a possible increase in sexually transmitted infections (STI); and the problem of monitoring adherence.
The high costs of drugs to be used for PrEP in HIV negative individuals and the possible competition with the availability of funding for ARV treatment of infected persons and for other preventive measures such as information campaigns, were considered difficult-to-resolve ethical issues.
The specialists did not find an agreement on PrEP target populations. The majority agreed to consider PrEP in case of stable serodiscordant couples who wish to conceive, in particular when the HIV negative partner is the woman, while they would be more careful in offering PrEP to individuals who report high-risk sexual behaviours, mainly for the fear of sexual disinhibition.
Finally, participants expressed the need for institutional recommendations, and their willingness to participate in PrEP trials.
The questionnaire was returned by 311 physicians (overall response rate 40%), 40% of whom completed the online survey.
Thirty per cent of specialists (n = 95) would not prescribe PrEP in any case. Of the remaining 216, 81% would prescribe it to high-risk subjects in some circumstances, and 93% to serodiscordant partners. Main target populations were men who have sex with men (MSM) not using condoms (55%), and serodiscordant individuals exposed to a viraemic partner (45%); PrEP to women for conception, regardless of the viral load of their partner, accounted for 71% (Table 1).
Demographic and working characteristics of the study population, experience with HIV-infected patients, practice and knowledge, overall and according to the attitude towards PrEP prescription, are shown in Table 2.
The majority of the respondents were males, aged >50 years, working in non-teaching hospitals, with inpatients, for more than 20 years.
Most participants had experience of the use of ARV in HIV negative persons (255, 82%); 85% had prescribed less than 20 HIV tests in the last month.
Overall, self-evaluation of PrEP knowledge was reported as at least sufficient in 69% of cases. At univariate analysis, no differences were found between specialists with a positive or negative attitude towards PrEP prescription according to demographic characteristics, working experience, experience with HIV-infected patients, or self-reported knowledge.
A positive attitude was more frequent among those who participated in the HIV educational courses, had prescribed ARV to negative individuals to prevent HIV infection, and used to inform their patients previously on PEP. All these factors remained significantly associated with a positive attitude at multivariate analysis (Table 2). The model demonstrated adequate goodness of fit, Hosmer-Lemeshow χ8 = 10.195, p = 0.252, and accounted for 17.2% of the variance.
Participants' perception of PrEP and their main concerns, overall and according to attitude towards prescription, are shown in Table 3.
Regardless of their attitude, the large majority of respondents agreed that encouraging access to HIV testing and care, and behavioural interventions, are more effective (91% and 74%, respectively) and safer (89%), than PrEP; regarding PrEP possible effect on testing frequency, respondents split evenly.
Main concerns were, in order: efficacy, costs, increase in risk behaviours and STI, side effects, risk of drug resistance and adherence. In addition, 70% of HIV specialists felt uncomfortable in prescribing ARV for new indications in absence of clear evidence of effectiveness and safety, while 90% disagreed to lack time for engaging in prevention counselling and PrEP monitoring.
Regarding prescription barriers, specialists who would prescribe PrEP are less concerned by potential toxicity and use of drugs for new indications (OR 2.39 and 2.01, respectively); moreover, they are more likely to disagree that behavioural interventions could be more effective than PrEP (OR 3.78), or that PrEP could lead to a decreased attitude to test regularly (OR 1.63).
Overall, most respondents believed that NHS should sustain PrEP costs: entirely, in all (28%) or selected (9%) cases (i.e. conception), or partially, based on patient's income (29%). Of the remaining, 31% would charge the patient, and 3% did not answer. Specialists who would prescribe PrEP are more likely to support NHS participation in covering PrEP costs (OR 4.63; 95% CI 2.74–7.84). Of the two items not included in the pilot session (denominator = 279 specialists), in the hypothetical scenario, of 271 respondents 55% would choose only counselling on safe sex to protect the uninfected partner, while 27% would add ARV to the infected partner, 8% PrEP to the negative partner, and 10% both.
Those with a positive attitude towards PrEP prescription are definitely more likely to add PrEP, alone or in combination with TasP, to prevent transmission (OR 4.46; 95% CI 1.78–11.16). As for the framework for PrEP prescription, 79% considered appropriate the issue of formal guidelines (not recommended 11%; 10% did not answer), and 60% the start of a multicenter trial (not recommended 22%; 18% did not answer). Those who would prescribe PrEP are more prone to provide it within the framework of a multicenter trial (OR 3.95; 95% CI 2.14–7.30; p < 0.001) and national/international PrEP guidelines (OR 3.37; 95% CI 1.51–7.51; p = 0.003).
Results
Focus Group
Most focus group participants reported a "not detailed" knowledge about the results of published PrEP trials, and expressed concerns regarding PrEP use. The main concerns that emerged were: duration of use, side effects and long term toxicities; ARV resistance; a possible increase in sexually transmitted infections (STI); and the problem of monitoring adherence.
The high costs of drugs to be used for PrEP in HIV negative individuals and the possible competition with the availability of funding for ARV treatment of infected persons and for other preventive measures such as information campaigns, were considered difficult-to-resolve ethical issues.
The specialists did not find an agreement on PrEP target populations. The majority agreed to consider PrEP in case of stable serodiscordant couples who wish to conceive, in particular when the HIV negative partner is the woman, while they would be more careful in offering PrEP to individuals who report high-risk sexual behaviours, mainly for the fear of sexual disinhibition.
Finally, participants expressed the need for institutional recommendations, and their willingness to participate in PrEP trials.
Study Population
The questionnaire was returned by 311 physicians (overall response rate 40%), 40% of whom completed the online survey.
Thirty per cent of specialists (n = 95) would not prescribe PrEP in any case. Of the remaining 216, 81% would prescribe it to high-risk subjects in some circumstances, and 93% to serodiscordant partners. Main target populations were men who have sex with men (MSM) not using condoms (55%), and serodiscordant individuals exposed to a viraemic partner (45%); PrEP to women for conception, regardless of the viral load of their partner, accounted for 71% (Table 1).
Demographic and working characteristics of the study population, experience with HIV-infected patients, practice and knowledge, overall and according to the attitude towards PrEP prescription, are shown in Table 2.
The majority of the respondents were males, aged >50 years, working in non-teaching hospitals, with inpatients, for more than 20 years.
Most participants had experience of the use of ARV in HIV negative persons (255, 82%); 85% had prescribed less than 20 HIV tests in the last month.
Overall, self-evaluation of PrEP knowledge was reported as at least sufficient in 69% of cases. At univariate analysis, no differences were found between specialists with a positive or negative attitude towards PrEP prescription according to demographic characteristics, working experience, experience with HIV-infected patients, or self-reported knowledge.
A positive attitude was more frequent among those who participated in the HIV educational courses, had prescribed ARV to negative individuals to prevent HIV infection, and used to inform their patients previously on PEP. All these factors remained significantly associated with a positive attitude at multivariate analysis (Table 2). The model demonstrated adequate goodness of fit, Hosmer-Lemeshow χ8 = 10.195, p = 0.252, and accounted for 17.2% of the variance.
Participants' perception of PrEP and their main concerns, overall and according to attitude towards prescription, are shown in Table 3.
Regardless of their attitude, the large majority of respondents agreed that encouraging access to HIV testing and care, and behavioural interventions, are more effective (91% and 74%, respectively) and safer (89%), than PrEP; regarding PrEP possible effect on testing frequency, respondents split evenly.
Main concerns were, in order: efficacy, costs, increase in risk behaviours and STI, side effects, risk of drug resistance and adherence. In addition, 70% of HIV specialists felt uncomfortable in prescribing ARV for new indications in absence of clear evidence of effectiveness and safety, while 90% disagreed to lack time for engaging in prevention counselling and PrEP monitoring.
Regarding prescription barriers, specialists who would prescribe PrEP are less concerned by potential toxicity and use of drugs for new indications (OR 2.39 and 2.01, respectively); moreover, they are more likely to disagree that behavioural interventions could be more effective than PrEP (OR 3.78), or that PrEP could lead to a decreased attitude to test regularly (OR 1.63).
Overall, most respondents believed that NHS should sustain PrEP costs: entirely, in all (28%) or selected (9%) cases (i.e. conception), or partially, based on patient's income (29%). Of the remaining, 31% would charge the patient, and 3% did not answer. Specialists who would prescribe PrEP are more likely to support NHS participation in covering PrEP costs (OR 4.63; 95% CI 2.74–7.84). Of the two items not included in the pilot session (denominator = 279 specialists), in the hypothetical scenario, of 271 respondents 55% would choose only counselling on safe sex to protect the uninfected partner, while 27% would add ARV to the infected partner, 8% PrEP to the negative partner, and 10% both.
Those with a positive attitude towards PrEP prescription are definitely more likely to add PrEP, alone or in combination with TasP, to prevent transmission (OR 4.46; 95% CI 1.78–11.16). As for the framework for PrEP prescription, 79% considered appropriate the issue of formal guidelines (not recommended 11%; 10% did not answer), and 60% the start of a multicenter trial (not recommended 22%; 18% did not answer). Those who would prescribe PrEP are more prone to provide it within the framework of a multicenter trial (OR 3.95; 95% CI 2.14–7.30; p < 0.001) and national/international PrEP guidelines (OR 3.37; 95% CI 1.51–7.51; p = 0.003).
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