Preparing for PrEP: Perceptions and Readiness of Canadian Physicians for the Implementation of HIV Pre-Exposure Prophylaxis

<div><p>Recent evidence has demonstrated the efficacy of pre-exposure prophylaxis (PrEP) for HIV prevention, but concerns persist around its use. Little is known about Canadian physicians' knowledge of and willingness to prescribe PrEP. We disseminated an online survey to Canadian family, infectious disease, internal medicine, and public health physicians between September 2012–June 2013 to determine willingness to prescribe PrEP. Criteria for analysis were met by 86 surveys. 45.9% of participants felt “very familiar” with PrEP, 49.4% felt that PrEP should be approved by Health Canada, and 45.4% of respondents were willing to prescribe PrEP. Self-identifying as an HIV expert (odds ratio, OR = 4.1, 95% confidence interval, CI = 1.6–10.2), familiarity with PrEP (OR = 5.0, 95%CI = 1.3–19.0) and having been asked by patients about PrEP (OR = 4.0, 95%CI = 1.5–10.5) were positively associated with willingness to prescribe PrEP on univariable analysis. The latter two were the strongest predictors on multivariate analysis. Participants cited cost and efficacy as major concerns. 75.3% did not feel that information had been adequately disseminated among physicians. In summary, Canadian physicians demonstrate varying levels of support for PrEP and express concerns about its implementation. Further research on real-world effectiveness, continuing medical education, and clinical support is needed to prepare physicians for this prevention strategy.</p></div

Physician perceptions of PrEP.

<p>Physician perceptions of PrEP.</p

Respondent demographics.

a<p>Responses may not sum to 86 due to missing values.</p>b<p>Values shown are number (percentage) or median (IQR).</p

Familiarity with and attitudes regarding PrEP^a.

a<p>Values shown are number (percentage) or median (IQR).</p>b<p>Responses may not sum to 86 due to missing values.</p>c<p>Proportion of respondents willing to prescribe PrEP based on current knowledge for high-risk patients who have a mechanism to cover medication costs.</p>d<p>Response to question “According to one study among men who have sex with men (MSM), oral PrEP provided 44% protection against HIV infection overall and 73% protection in participants who used PrEP consistently (i.e. took the medication on a regular schedule and did not miss doses). Other studies show that PrEP provides a similar level of protection among heterosexual men and women. Considering this level of protection, do you believe Health Canada should approve PrEP for use in Canada?”</p

Considerations in the implementation of PrEP ranked by order of importance.

<p>Bars represent percentage of respondents.</p

Minimum acceptable level of protection afforded by (PrEP) according to participant opinion on Health Canada Approval of PrEP in Canada.

<p>Histogram demonstrating the distribution of minimum acceptable PrEP efficacy according to whether study participants believe that PrEP should be approved for use by Health Canada. Respondents were asked “What is the MINIMUM level of protection you would consider reasonable for PrEP use to be recommended to individuals at high risk of HIV infection?” Respondents were then divided based on whether they answered yes (‘‘yes’’) or no or maybe (‘‘no’’) to the question: “According to one study among MSM, oral PrEP provided 44% protection against HIV infection overall and 73% protection in participants who used PrEP consistently (i.e. took the medication on a regular schedule and did not miss doses). Other studies show that PrEP provides a similar level of protection among heterosexual men and women. Considering this level of protection, do you believe Health Canada should approve PrEP for use in Canada?’’</p

Factors associated with willingness to prescribe PrEP.

<p>Factors associated with willingness to prescribe PrEP.</p

Novel imaging modalities for the comparison of bone microarchitecture among HIV+ patients with and without fractures: a pilot study

<p><b>Background:</b> HIV-infected adults have increased fracture risk.</p> <p><b>Objectives:</b> To generate pilot data comparing bone density, structure, and strength between HIV-infected adults with and without a prior fracture.</p> <p><b>Methods:</b> Adults with and without a prior fracture after their HIV diagnosis were matched 1:1 based on age, sex, race, and smoking history. Participants underwent dual-energy X-ray absorptiometry (DXA), trabecular bone score (TBS), hip structural analyses (HSA), vertebral fracture assessment (VFA), high-resolution peripheral quantitative tomography (HR-pQCT) and measurement of bone turnover markers. Results were compared between cases and controls, with differences expressed as percentages of control group values.</p> <p><b>Results:</b> 23 pairs were included. On DXA, cases had lower areal bone mineral density (aBMD) at the total hip (median difference in T-score −0.25, <i>p</i> = 0.04), but not the lumbar spine (median difference in T-score 0.10, <i>p</i> = 0.68). Cases had greater abnormalities in HSA and most HR-pQCT and HSA measures, by up to 15%. VFA revealed two subclinical fractures among cases but none among controls. TBS, CTX, and P1NP levels were similar between groups, with differences of 1.9% (<i>p</i> = 0.90), 9.7% (<i>p</i> = 0.55), and 10.0% (<i>p</i> = 0.24), respectively. For each parameter, we report the median and interquartile range for the absolute and relative difference between cases and controls, the correlation between cases and controls, and our recruitment rates, to inform the design of future studies.</p> <p><b>Conclusions:</b> These pilot data suggest potential differences in bone structure, estimated bone strength, and asymptomatic vertebral fractures among HIV-infected adults with and without fracture, warranting further study as markers of fracture risk in HIV.</p

Unadjusted odds ratios (95% confidence intervals) quantifying the bivariable relationships between four syndemic conditions (n = 186 MSM).

<p>Unadjusted odds ratios (95% confidence intervals) quantifying the bivariable relationships between four syndemic conditions (n = 186 MSM).</p

Syndemic conditions and attitude scales in study cohort (n = 186 MSM).

<p>Syndemic conditions and attitude scales in study cohort (n = 186 MSM).</p