Health Care Provider Decisions to Initiate Oral HIV Preexposure Prophylaxis in New York City Public Sexual Health Clinics

Abstract

Background: Oral HIV preexposure prophylaxis (PrEP) is safe and effective but underutilized. Health care providers' beliefs about PrEP and attitudes toward people who could benefit may affect PrEP access.

Methods: This mixed-methods study (2016-2018) was conducted in 8 New York City public sexual health clinics that implemented a PrEP program. Data included 32 in-depth qualitative interviews with clinicians, quantitatively coded to reflect their PrEP beliefs; a provider questionnaire; and 6 months of medical record visit data for these providers. Among patients with a PrEP indication, we examined the odds of a patient being initiated on PrEP associated with providers' PrEP beliefs and demographic characteristics, and patient characteristics.

Results: Providers reported strong support for offering PrEP to eligible patients. The majority denied concerns about possible development of drug-resistant viral strains, giving PrEP to people who might not benefit, and PrEP toxicity. Nevertheless, about one-third agreed with each of these concerns, and 55% thought PrEP use might limit condom use. Of 2176 patients with a PrEP indication, 20% were initiated. Providers with more restrictive PrEP beliefs did not have lower odds of initiating patients on PrEP. Women as well as Black and Latinx patients were less likely to be initiated on PrEP.

Conclusions: Contrary to our hypotheses, providers' negative PrEP beliefs did not seem to reduce initiation of PrEP for eligible patients. This may be attributable to clear clinical protocols, strong staff support, and training on implementing PrEP in this setting. Racial and gender disparities in PrEP uptake urgently require attention.

Figure 1.. Inclusion & exclusion criteria among patient-visits by 32 providers, Sexual Health Clinics, New York City, 2017–2018

¹ Included visits occurring in the 182 days prior to interview date. Excludes visits if a) Patient is HIV-positive, b) Visit occurred prior to PrEP initiation roll-out, c) Patient initiated PrEP at SHC prior to DOV, d) Patient medically evaluated for PrEP at SHC prior to current visit ² Ineligible for PrEP initiation if: a) patient aged <18 years, b) Visit occurred on a Saturday, c) Non-NYC resident, d) patient received PEP medication at current visit ³ Indication for PrEP if: a) patient self-reported at triage or navigation on DOV one or more of the following in the last 12 months: sex partner or needle sharing with PLWH, PEP use, syphilis diagnosis, and/or rectal gonorrhea or chlamydia, b) patient was clinically diagnosed with syphilis on DOV or at a SHC visit in the last 12 months, c) patient had a positive rectal gonorrhea and/or chlamydia test at a SHC visit in the last 12 months, d) patient is a woman with a positive gonorrhea test at a SHC visit in the last 12 months from any anatomic site, e) patient self- reported interest in PrEP at triage or navigation on DOV