Psychiatry and Family Medicine Residents' Likelihood of Prescribing HIV Pre-exposure Prophylaxis to Patients With Mental Illness and HIV Vulnerability

Abstract

Background: People living with mental illness (PLMI) experience disproportionately high incidence of and vulnerability to HIV. Pre-exposure prophylaxis (PrEP) is an effective and safe HIV prevention method, but data regarding prescription to PLMI are lacking. Psychiatrists may serve as important points of access for PrEP prescription for PLMI.

Methods: We conducted a vignette-based study of residents in psychiatry and family medicine (FM) to assess likelihood of prescribing PrEP and assumptions about the fictional patient. Participants were randomized to one of five vignettes in which the patients' psychiatric diagnosis was varied (schizophrenia on long-acting injectable or oral antipsychotic, bipolar disorder, major depression) or a control vignette without a psychiatric diagnosis.

Results: A total of 439 residents participated. We found that high percentages of psychiatry (96.8%) and FM (97.4%) residents were aware of PrEP. High percentages of psychiatry (92.0%-98.1%) and FM (80.8%-100%) residents reported that PrEP was indicated for all patient conditions. Family medicine residents were more likely to prescribe PrEP to all experimental conditions than psychiatry residents. There was no difference in likelihood of prescribing to the control condition without a psychiatric diagnosis. The belief that PrEP prescription was out of scope of practice was greater among psychiatry residents.

Conclusions: A majority of psychiatry residents responded that PrEP was indicated for an array of patients with psychiatric diagnoses. However, psychiatry residents were broadly less likely to prescribe PrEP to patients with these diagnoses. The high percentage of psychiatry residents who reported that PrEP was indicated for all patients suggests that additional training is needed to facilitate PrEP prescription by psychiatrists.

Figure 1.

Representative vignette which was presented to participants. All vignettes were accompanied by laboratory study results, including negative results for bacterial sexually transmitted infections (STIs) and a negative HIV antigen/antibody test. Vignettes varied psychiatric diagnoses and associated medications for psychiatric diagnosis, as emphasized for display in bold text for emphasis only (not displayed to participants). In the conditions in which the patient was described as having a psychiatric history, we indicated that the patient was presenting to an outpatient clinic for follow-up and the specialty of the clinic was not specified. The control condition was similar but instead had no psychotropic medications indicated on the patient’s medication list.

Figure 2.

A: Participant’s awareness of PrEP and different PrEP modalities. B: PrEP indication for patients by experimental condition and participant specialty. C: Recommended PrEP modality for patients by experimental condition and participant specialty. ***p < .001 Abbreviations/Acronyms: SCZ-LAI: Schizophrenia treated with long acting injectable paliperidone; SCZ-Oral: Schizophrenia treated with oral risperidone; MDD: Major depressive disorder; FM: Family Medicine; Psych: Psychiatry

Figure 3.

A: Participants’ mean rating of all assumption items for the patient by condition. Analyses of the assumption items controlled for participants’ specialty. B: Participants’ mean rating on assumption of patient adherence to PrEP at the intersection of condition and participant specialty. C: Participants’ mean rating on assumption of patient stopping condom use after being prescribed PrEP at the intersection of condition and participant specialty. D: Participants’ mean rating on assumption of patient increasing sexual partners after being prescribed PrEP at the intersection between condition and participant specialty. E: Participants’ mean rating on assumption of patient returning for follow-up care after being prescribed PrEP at the intersection of condition and participant specialty. F: Participants’ mean rating on likelihood of prescribing PrEP to the patient at the intersection of condition and participant specialty. **p < .01, ***p < .001 Abbreviations/Acronyms: SCZ-LAI: Schizophrenia treated with long acting injectable paliperidone; SCZ-Oral: Schizophrenia treated with oral risperidone; MDD: Major depressive disorder; FM: Family Medicine; Psych: Psychiatry

Figure 4.

A: Mean level of agreement that the belief that PrEP prescription was out of participants’ scope of practice affected likelihood of prescribing PrEP. B: Mean level of agreement that the belief that the presented patient was not at risk for HIV affected likelihood of prescribing PrEP. C: Mean level of agreement that the belief that the presented patient would not adhere to PrEP affected likelihood of prescribing PrEP. ***p < .001 Abbreviations/Acronyms: SCZ-LAI: Schizophrenia treated with long acting injectable paliperidone; SCZ-Oral: Schizophrenia treated with oral risperidone; MDD: Major depressive disorder; FM: Family Medicine; Psych: Psychiatry