PrEP Prescription Pickups Vary With Prescriber Specialty

Preexposure prophylaxis prescription reversals and abandonments were lower for patients seen by primary care clinicians than by other noninfectious disease clinicians, based on data from approximately 37,000 individuals.
Although preexposure prophylaxis (PrEP) has been associated with a reduced risk of HIV (human immunodeficiency virus) infection when used as prescribed, the association between PrEP prescription pickup and specialty of the prescribing clinician has not been examined, wrote Lorraine T. Dean, ScD, an epidemiologist at Johns Hopkins University, Baltimore, Maryland, and colleagues.
“HIV PrEP is highly effective at preventing new HIV cases, and while use is on the rise, is still used much less than it should be by people who are at risk of HIV,” Dr Dean said in an interview. “This study is helpful in pinpointing who is at risk for not picking up PrEP and in helping us think through how to reach them so that they can be better positioned to get PrEP,” she said.
In a study published in JAMA Internal Medicine, the researchers reviewed data for PrEP care. The study population included 37,003 patients aged 18 years and older who received new insurer-approved PrEP prescriptions between 2015 and 2019. Most of the patients (77%) ranged in age from 25 to 64 years; 88% were male.
Pharmacy claims data were matched with clinician data from the US National Plan and Provider Enumeration System.
Clinicians were divided into three groups: Primary care providers (PCPs), infectious disease specialists (IDs), and other specialists (defined as any clinician prescribing PrEP but not classified as a PCP or an ID specialist). The main binary outcomes were prescription reversal (defined as when a patient failed to retrieve a prescription) and abandonment (defined as when a patient neglected to pick up a prescription for 1 year).
Overall, of 24,604 patients 67% received prescriptions from PCPs, 3,571 (10%) received prescriptions from ID specialists, and 8828 (24%) received prescriptions from other specialty clinicians.
The prevalence of reversals for patients seen by PCPs, ID specialists, and other specialty clinicians was 18%, 18%, and 25%, respectively. The prevalence of abandonments by clinician group was 12%, 12%, and 20%, respectively.
In a regression analysis, patients prescribed PrEP by ID specialists had 10% lower odds of reversals and 12% lower odds of abandonments compared to those seen by PCPs (odds ratio 0.90 and 0.88, respectively). However, patients seen by other clinicians (not primary care or ID) were 33% and 54% more likely to have reversals and abandonments, respectively, compared with those seen by PCPs.
Many patients at risk for HIV first see a PCP and then are referred to a specialist, such as an ID physician, Dr Dean said. “The patients who take the time to then follow up with a specialist may be most motivated and able to follow through with the specialist’s request, in this case, accessing their PrEP prescription,” she said. In the current study, the researchers were most surprised by how many other specialty providers are involved in PrEP care, which is very positive given the effectiveness of the medication, she noted.
“Our results suggest that a wide range of prescribers, regardless of specialty, should be equipped to prescribe PrEP as well as offer PrEP counseling,” Dr Dean said. A key takeaway for clinicians is that PrEP should have no cost for the majority of patients in the United States, she emphasized. The absence of cost expands the population who should be interested and able to access PrEP, she said. Therefore, providers should be prepared to recommend PrEP to eligible patients and seek training or continuing medical education for themselves so they feel equipped to prescribe and counsel patients on PrEP, she said.
“One limitation of this work is that, while it can point to what is happening, it cannot tell us why the reversals are happening; what is the reason patients prescribed by certain providers are more or less likely to get their PrEP,” Dr Dean explained. “We have tried to do interviews with patients to understand why this might be happening, but it’s hard to find people who aren’t showing up to do something, compared to finding people who are showing up to do something,” she said. Alternatively, researchers could interview providers to understand their perspective on why differences in prescription pickups occur across specialties, she said.
Looking ahead, “a national PrEP program that includes elements of required clinician training could be beneficial, and research on how a national PrEP program could be implemented and impact HIV rates would be helpful in considering this strategy of prevention,” said Dr Dean.
Support All Prescribers to Increase PrEP Adherence
Differences in uptake of PrEP prescriptions may be explained by the different populations seen by various specialties, Meredith Green, MD, of Indiana University School of Medicine, Indianapolis, and Lona Mody, MD, of the University of Michigan, Ann Arbor, wrote in an accompanying editorial. However, the key question is how to support all prescribers and promote initiation and adherence to PrEP, they said.
Considerations include whether people at risk for HIV prefer to discuss PrEP with a clinician they already know, vs a new specialist, but many PCPs are not familiar with the latest PrEP guidelines, they said.
“Interventions that support PrEP provision by PCPs, especially since they prescribed the largest proportion of PrEP prescriptions, can accelerate the uptake of PrEP,” the editorialists wrote.
“Supporting a diverse clinician workforce reflective of communities most impacted by HIV will remain critical, as will acknowledging and addressing HIV stigma,” they said. Educational interventions, including online programs and specialist access for complex cases, would help as well, they said. The approval of additional PrEP agents since the current study was conducted make it even more important to support PrEP prescribers and promote treatment adherence for those at risk for HIV, Dr Green and Dr Mody emphasized.
The study was funded by the National Institutes of Health. Dr Dean had no financial conflicts to disclose. Dr Green disclosed grants from Gilead and royalties from Wolters Kluwer unrelated to the current study; she also disclosed serving on the Centers for Disease Control and Prevention/Health Resources and Services Administration advisory committee on HIV, viral hepatitis, and sexually transmitted infection prevention and treatment. Dr Mody disclosed grants from the US National Institute on Aging, Veterans Affairs, Centers for Disease Control and Prevention, NanoVibronix, and UpToDate unrelated to the current study.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.