Antiretroviral medications for HIV prevention: What do providers think, say, and do?Douglas Krakower, MDOctober 30, 2013

• Current funding:• National Institute of Mental Health (NIMH K23

MH098795-01)

• Additional project support:• Bristol-Myers-Squibb Virology Fellowship• Gilead Sciences• AMA Foundation Research Seed Grant

Potential Competing Interests

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Before HPTN 052 and updated guidelines, few clinicians intended to prescribe early ART

Kurth JAIDS 2012

Clinicians cited reasons why they would defer ART for HIV-infected patients

Kurth JAIDS 2012

Willingness to prescribe PrEP to MSM is high

Puro BMC Infect Dis 2013

Many would offer PrEP to members of serodiscordant couples

Puro BMC Infect Dis 2013

Some providers would discontinue PrEP if adherence is low, or if partner is undetectable

Karris Emerging Infections Network 2013

In 2012, we conducted 6 focus groups with Boston HIV providers to assess facilitators/barriers to prescribing early ART (and PrEP)

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Prescribe early ART

Positive attitudes

Additional evidence that individuals will benefit from early ART

Normative guidelines

Prioritize individual health

benefits over prevention

considerations

Patient readiness and anticipated adherence as

primary determinants of

prescribing

++

+

HIV providers endorse early ART; base prescribing decisions primarily on whether ART will benefit individual patients

-

-

Krakower Forum Collab HIV Res 2012

Focus groups, Boston (n=39 HIV providers)

Perceived efficacyPatient factors

MotivationSpecific clinical scenariosLack of empowermentAnticipated high adherence

Social normsPeer normsGuidelines

Temporary use

Facilitators to prescribing PrEP

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Purview paradox: contradictory beliefs about which providers will prescribe PrEP

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HIV providersPrimary care

providers are in the best position to prescribe PrEP

Primary care providers

It would not be feasible to prescribe

PrEP

Purview paradox

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Practical issue number one is that the people who are going to be prescribing these drugs in theory, who are going to be in the best position, are going to be primary care providers with little or no HIV experience. –Generalist/HIV specialist

I think that the idea of adding to what I just did this morning and adding a discussion with my patients about what is their likelihood of having sexual encounters with patients who are HIV-infected, and then on top of that trying to prescribe and get approved medication like Truvada or some other pre-exposure prophylaxis… I just can’t imagine it working in the hands of a primary care doctor.–Generalist/HIV specialist

Krakower and Mayer, Ann Int Med 2012

There is a need to understand how primary care providers approach the decision to prescribe PrEP

Need to better understand:• clinician attitudes and practices regarding

early ART since 052• pt-provider communication regarding

initiating early ART (and PrEP)• how to translate positive clinician attitudes

towards PrEP into successful prescribing• creative ways to engage diverse providers

in PrEP implementation

In summary, major gaps exists in our understanding of how to optimize providers’ prescribing practices

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Thank you! (dkrakowe@bidmc.harvard.edu)

The Fenway Institute, BIDMCKen Mayer (Primary Mentor)Jennifer Mitty, Matthew Mimiaga, Charlene

Flash, Kevin Maloney, Jackie White, The entire Fenway Research StaffHarvard School of Public HealthNorma WareBrownIra WilsonTuftsJohn WongMGHDavid Bangsberg

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