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

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

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

Trends in the awareness, acceptability, and usage of HIV pre-exposure prophylaxis among at-risk men who have sex with men in Toronto

Objectives: Pre-exposure prophylaxis (PrEP) with daily oral tenofovir/emtricitabine dramatically reduces HIV risk in men who have sex with men (MSM). However, uptake is slow worldwide. Methods: We administered anonymous cross-sectional questionnaires to MSM presenting for anonymous HIV testing at a Toronto sexual health clinic at four successive time points during the period 2013-2016. We assessed trends in PrEP awareness, acceptability, and use over time using the Cochran-Armitage Trend Test, and identified barriers to using PrEP by constructing "PrEP cascades" using 2016 data. We assumed that to use PrEP, MSM must (a) be at risk for HIV, (b) be at objectively high risk (HIRI-MSM score ≥ 10), (c) perceive themselves to be at medium-to-high risk, (d) be aware of PrEP, (e) be willing to use PrEP, (f) have a family doctor, (g) be comfortable discussing sexual health with that doctor, and (h) have drug coverage/be willing to pay out of pocket. Results: MSM participants were mostly white (54-59.5%), with median age 31 years (IQR = 26-38). PrEP awareness and use increased significantly over time (both p Conclusion: To maximize its potential public health benefits, PrEP scale-up strategies must address self-perceived HIV risk and increase access to PrEP providers.</p

Acceptability and tolerability of and adherence to HIV pre-exposure prophylaxis among Toronto gay and bisexual men: a pilot study

Background: Preexposure prophylaxis is efficacious at preventing HIV infection, but concerns persist about adherence and sexually transmitted infections (STIs). We assessed preexposure prophylaxis acceptability, adherence and clinical outcomes in a pilot demonstration project. Methods: HIV-uninfected adult gay and bisexual men who scored 10 or higher on a validated HIV risk score (HIV Incidence Risk Index for MSM) and reported condomless receptive anal sex were sequentially enrolled into a 1-year open-label single-arm pilot study of daily oral therapy with tenofovir disoproxil fumarate/emtricitabine in Toronto. The primary outcome was acceptability of preexposure prophylaxis. Secondary outcomes were preexposure prophylaxis adherence (4-d recall, pill count and dried blood spot analysis), HIV seroconversion, STIs and adverse events. Results: Of the 86 men screened, 52 were enrolled. Participants were mostly young (median age 33 yr [interquartile range (IQR) 28–37 yr) white (38 [73%]) gay (49 [94%]) men. Preexposure prophylaxis acceptability was high: all participants reported their experience as “good” or “very good.” The median adherence rate was high, at 100% (IQR 95%–100%) by self-report and 96.9% (IQR 93.4%–98.4%) by pill count. Dried blood spot analysis suggested that doses were taken 4–7 days/week at 88.7% (173/195) of month 3–12 visits. No cases of HIV seroconversion occurred, but 25 participants (48%) experienced at least 1 bacterial STI, with incidence rates per 100 person-years of 32.8, 32.8, 8.2 and 8.2 for chlamydia, gonorrhea, syphilis and lymphogranuloma venereum, respectively. No adverse events led to discontinuation of prophylaxis, but the estimated glomerular filtration rate declined by 0.22 mL/min per month. Interpretation: Preexposure prophylaxis was associated with high adherence and acceptability and no HIV infections in this study. Frequent STIs and clinically unapparent toxic renal effects reinforce the need for ongoing vigilance.</p