The role of healthcare providers in the roll out of preexposure prophylaxis

Abstract

Purpose of review: To review the most recent studies assessing the preparedness of healthcare practitioners to provide anti-HIV preexposure prophylaxis (PrEP) and suggest areas for future implementation research.

Recent findings: As PrEP is a biobehavioral intervention, healthcare providers are likely to play a critical role in implementing PrEP in care settings. Studies suggest that many specialized providers are aware of PrEP and support its provision as a public health intervention, though knowledge and acceptance are less among generalists. Therefore, utilization of PrEP by clinicians has been limited to a few early adopters. Concerns about the efficacy and long-term safety of PrEP, and perceived barriers to prescribing PrEP, could limit prescribing behaviors and intentions. Resistance to performing routine HIV risk assessments by clinicians is an additional barrier to implementing PrEP, although innovative tools to help clinicians routinely perform risk assessments, are being developed.

Summary: Interventions are needed to engage a broader array of healthcare providers in PrEP provision. Utilizing a framework based on diffusion of innovation theory, this review proposes strategies that can be implemented and evaluated to increase PrEP prescribing by healthcare providers. If resources are invested in training clinicians to provide PrEP, then these stakeholders could enhance the use of PrEP as part of a prevention package by primary providers.

Figure 1. Hypothetical Provider “Cascade” for PrEP

Schematic to represent the steps in the continuum of provider knowledge and experience with providing PrEP. This schematic can be applied to the global community of healthcare providers or to specific subgroups of providers with similar geography (e.g., the United States) or professional background (e.g., primary care providers). Heights of bar graphs are hypothetical for the purposes of illustration, given heterogeneity of provider engagement and incomplete data on provider opinions and practices. The arrows represent favorable amplification effects from engaging providers as “trainers” for their colleagues.

Figure 2. Temporal Diffusion of PrEP as a Medical Innovation

The uptake of medical innovations such as PrEP tends to follow an S-shaped curve, with early use limited to a small proportion of the total population (innovators (2.5% of all providers) and early adopters (13.5%), with subsequent expansion to early (34%) and late (34%) majorities, and finally adoption by traditionalists, or “laggards” (16%) (40). For PrEP, clinician assessments suggest that uptake has only occurred among innovators or early adopters, without attainment of an “inflection point,” so widespread adoption remains uncertain. The current state of PrEP adoption by clinicians (i.e., in 2015) is represented by the star. Diffusion of innovation theory suggests several strategies to support adoption of PrEP by larger numbers of clinicians, as described in the text.