US HIV physicians routinely offering early ART but only a third have prescribed PrEP

Most doctors at the frontline of the HIV epidemic in the United States recommend early antiretroviral therapy (ART) and many also believe they have a role in providing pre-exposure prophylaxis (PrEP) to the uninfected partners of their patients living with HIV, according to research published in the online edition of Clinical Infectious Diseases. Overall, 87% of doctors recommended ART from the point of diagnosis and most thought PrEP appropriate in some circumstances. However, only a third had actually prescribed PrEP.

ART is an important component of HIV prevention strategies. There is now overwhelming evidence that virologically suppressive ART reduces the risk of HIV transmission to negligible levels. PrEP has also been shown to substantially reduce the risk of infection with HIV for at risk HIV-negative gay men and transgender women.

US treatment guidelines have recommended early ART since 2012 and in May 2014 the Centers for Disease Control and Prevention (CDC) released comprehensive guidelines concerning the use of PrEP.

Studies conducted before the release of these guidelines showed that few frontline doctors were offering early ART and that even fewer had experience of offering PrEP. Investigators wanted to see if this had now changed. They therefore surveyed clinicians involved in the Emerging Infections Network, an association of infectious diseases physicians in the US and Canada. In May 2014 members were sent a questionnaire about use of early ART, their experience of PrEP and the provision of other recommended HIV prevention interventions, for instance clean syringes and opioid substitution for people who inject drugs.

Of the 1191 active members in the network, 573 responded (48%). A total of 415 respondents (72%) were HIV care providers.

The overwhelming majority of HIV providers (87%) indicated that they typically recommend ART from the time of HIV diagnosis, irrespective of CD4 count. However, 11% said they waited until a patient’s CD4 count dropped below 500 cell/mm³ and 2% delayed therapy until the 350 cell/mm³ threshold.

Lack of patient readiness was the main reason (95%) why doctors would not initiate ART when a patient had a CD4 count above 500 cells/mm³. Two-thirds would delay therapy in the context of uncontrolled drug or alcohol abuse, 49% if a patient would have problems meeting the cost of ART, and 45% when individuals had untreated mental health problems.

The majority of physicians (69%) believed that decisions about starting ART should be shared between themselves and patients.

Turning to PrEP, 80% of providers said they would recommend PrEP if a patient living with HIV had a detectable viral load, was unwilling to start ART and was in a sexual relationship with a HIV-negative partner with inconsistent condom use. Sub-optimal ART adherence by the partner with HIV was cited as a reason for recommending PrEP by three-quarters of physicians, but only 33% endorsed the use of PrEP in the context of an undetectable viral load.

In situations where a mixed HIV status couple were trying to conceive, 24% of doctors reported that in addition to ART for the partner with HIV, PrEP had also been used. Approximately a fifth reported that couples had attempted to conceive without the use of PrEP and 16% reported the use of sperm washing or assisted conception.

Most doctors considered aspects of PrEP provision to be part of their clinical role. This included counselling their patients who have HIV about PrEP (87%), offering appointments to discuss PrEP with HIV-negative partners (71%) and prescribing PrEP (68%). However, only 59% of physicians had actually talked to their patients about PrEP, even fewer (41%) had offered appointments to HIV-negative partners and less than a third (32%) had ever prescribed PrEP.

Half of physicians would prefer that doctors and patients shared decisions about the use of PrEP but 36% believed that patient preferences should guide decision making.

“Because only 59% of the study sample had actually counseled HIV-infected patients about PrEP, and only 1 in 3 respondents had prescribed PrEP to partners, clinicians may still be missing opportunities to provide PrEP,” comment the authors.

When asked about other recommended methods of HIV prevention, 80% said they had offered sterile needles and 68% had offered opioid substitution therapy routinely. However, only 42% thought that PrEP should be routinely offered to HIV-negative individuals who inject drugs, and just 24% felt adequately prepared to prescribe PrEP to drug users.

Doctors who deferred ART were less likely than providers who recommended early therapy to believe that they had a role counselling their patients who have HIV about PrEP (p = 0.002), discussing PrEP with partners (p = 0.02) or prescribing PrEP (p = 0.02).

“The findings of this study suggest that most infectious diseases providers who are HIV specialists in the United States generally recommend early ART and that many also perceive a role for themselves in providing PrEP to partners of their HIV-infected patients. However, only 1 in 3 clinicians had prescribed PrEP to partners, [and] many do not feel prepared to deliver protective interventions to PWID,” conclude the authors. “Investing in interventions to optimize practices among frontline infectious diseases specialists could have an appreciable impact on the HIV epidemic.”