JAIDS Journal of Acquired Immune Deficiency Syndromes:
HIV Medical Providers' Perceptions of the Use of Antiretroviral Therapy as Nonoccupational Postexposure Prophylaxis in 2 Major Metropolitan Areas
Rodríguez, Allan E. MD*; Castel, Amanda D. MD, MPH†; Parish, Carrigan L. DMD‡; Willis, Sarah MPH†; Feaster, Daniel J. PhD§; Kharfen, Michael BA‖; Cardenas, Gabriel A. MPH§; Villamizar, Kira BS, MPH¶; Kolber, Michael MD, PhD*; Vázquez-Rivera, Liliana MD*; Metsch, Lisa R. PhD‡
*Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida;
†Department of Epidemiology and Biostatistics, George Washington University, Washington, D.C.;
‡Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York;
§Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida;
‖District of Columbia Department of Health, HIV/AIDS, Hepatitis, STD, and TB Administration, Washington, D.C.; and
¶Miami-Dade County Health Department, Office of HIV/AIDS Services, Miami, Florida.
Correspondence to: Allan E. Rodríguez, MD, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 856, Miami, FL 33136 (e-mail: email@example.com).
Supported by supplemental funds to the Grant 5P30AI087714 (DC Developmental Center for AIDS Research) for the Enhanced Comprehensive HIV Prevention Planning Initiative (CFAR ECHPP Initiative) (grant P30AI087714).
Presented at the First National CFAR/APC ECHPP Conference, November 19, 2012, Washington, DC.
The authors have no conflicts of interest to disclose.
Introduction: In 2005, the Centers for Disease Control and Prevention expanded its recommendation of postexposure prophylaxis (PEP) use in the workplace to include nonoccupational exposures (nPEP). The availability and extensive use of nPEP have not achieved widespread acceptance among health-care providers of high-risk populations, and public health and primary care agencies have been sparse in their implementation of nPEP promotion, protocols, and practices.
Methods: We conducted a survey of HIV providers (n = 142, response rate = 61%) in Miami-Dade County (Florida) and the District of Columbia that focused on their knowledge, attitudes, beliefs, and practices related to the delivery of nPEP. We then analyzed differences in survey responses by site and by history of prescribing nPEP using bivariate and multivariate logistic regression.
Results: More District of Columbia providers (59.7%) reported ever prescribing nPEP than in Miami (39.5%, P < 0.048). The majority of practices in both cities did not have a written nPEP protocol and rarely or never had patients request nPEP. Multivariable analysis for history of prescribing nPEP was dominated by having patients request nPEP [odds ratio (OR) = 21.53] and the belief that nPEP would lead to antiretroviral resistance (OR = 0.14) and having a written nPEP protocol (OR = 7.49).
Discussion: Our findings are consistent with earlier studies showing the underuse of nPEP as a prevention strategy. The significance of having a written nPEP protocol and of patient requests for nPEP speaks to the importance of using targeted strategies to promote widespread awareness of the use of HIV antiretroviral medications as a prevention intervention.
The incidence rate of HIV in the United States still persists at approximately 50,000 new HIV infections annually and remains a significant public health burden.1 Prevention strategies continue to focus on decreasing disease transmission and incidence rates of new infections annually. The use of oral chemoprophylaxis by HIV-uninfected persons before or immediately after exposure to HIV is a promising prevention effort.2–5 Postexposure prophylaxis (PEP) has been studied extensively and demonstrated a protective effect through animal transmission models,6–8 perinatal clinical trials,9 and observational10,11 and case report12,13 studies of health-care workers after occupational exposures. These occupational studies have derived effectiveness data from health-care workers that have suggested a 79%–81% reduction in HIV infection attributed to the use of antiretroviral medications after a high-risk exposure.10,11
In response to these accumulating data on the efficacy of nPEP and the need for more widespread national guidelines on its use in medical facilities,14 the Centers for Disease Control (CDC) expanded its recommendation of PEP use in the workplace in 2005 to include nonoccupational exposures (nPEP).15 The use of nPEP is now recommended for uninfected persons seeking care less than 72 hours after exposure to potentially infected blood, genital secretions, or other bodily fluid in the setting of significant sexual or injection drug encounters with an individual of known positive serostatus.15 These revised guidelines also encourage adjunct behavior modification and risk reduction counseling to address behavioral and social cofactors that predispose nPEP users to high-risk engagement. When the HIV status of the source is unknown, the CDC states that “no recommendations are made either for or against the use of” nPEP and instead advises clinicians to prescribe nPEP based on a “case-by-case” evaluation, depending on what is known about the source and exposure. This puts considerable responsibility and discretion on the physician because of the high prevalence of undiagnosed infection in high-risk populations and the fact that the vast majority of patients presenting for postexposure care do not know the HIV status of the exposure source. One 2003 Rhode Island emergency department study reported that less than 2% of postexposure patients knew that their exposure source was HIV positive.16 Similarly, a 10-year 2010 retrospective cohort study of nPEP requests in a hospital outpatient clinic found that 77% of exposure sources had unknown serostatus, leading investigators to endorse the feasibility and efficiency of a prevention approach that involved the tracing and testing of the exposure source.5
nPEP has not achieved widespread acceptance among health-care providers of high-risk populations.17 Many concerns have been raised, including patient's nonadherence, pharmacological toxicities and adverse effects in otherwise healthy individuals, development of viral resistance and selection for resistant virus, the potentially high cost of therapy for patients without insurance or with inconsistent insurance coverage, and the difficulty in accessing medical care from a physician within the recommended 72 hours, given that persons most likely to benefit from nPEP may be estranged from the health-care system.15,18,19 Controversy also persists over the cost-effectiveness of nPEP in comparison with other HIV prevention methods, such as behavior modification counseling,20,21 or only in very limited circumstances, such as following receptive but not insertive anal intercourse,18,22 and whether continued emphasis on nPEP and HIV prevention may divert resources from HIV-positive patients to HIV-negative patients.23
Nonetheless, emerging evidence has supported nPEP use as a practical, cost-effective method of HIV prevention and mitigated concerns about nPEP-induced behavioral disinhibition. Feasibility studies have documented seroconversion prevention and yielded high percentage values of nPEP completion rates among nPEP users, despite some subjective reports of side effects.17,24 Cost-effectiveness has been demonstrated through empirically based economic analysis of a large-scale nPEP feasibility program implemented in San Francisco, where nPEP was administered to patients with varying sources and levels of exposure risk.25 A similar 2004 study conducted empirical, model-based analysis of nPEP cost-effectiveness in 96 metropolitan statistical areas (MSAs) in the United States and derived a cost-effectiveness ratio comparable with that of existing behavioral counseling interventions.24 Though nPEP was found to be most cost effective in MSAs with larger populations of men who have sex with men (MSM), especially those with high HIV prevalence, the results suggested that the use of antiretroviral medications after nPEP to HIV could be a cost-effective adjunct to existing HIV prevention efforts.
Attracting much attention is the concept that nPEP availability will lead to “treatment optimism” and attenuated risk perception, leading to continued or heightened engagement in high-risk behavior, commonly referred to as “behavioral disinhibition.”18,19 It has even been speculated that nPEP could cause net harm, protecting only a few nPEP users at the expense of widespread increased risk behavior and, consequently, increased disease transmission.19 Concerns about nPEP-induced behavioral disinhibition and promotion of risky behavior have been disproven through various studies, with some even demonstrating that, instead, the distribution of nPEP may have a beneficial effect on the behavior by acting as an “educable moment.”26 The 1999–2003 randomized HIV prevention trial EXPLORE studied approximately 4300 MSM in 6 national cities and showed that, although nPEP users remained a high-risk group, nPEP use did not seem to lead to increased sexual risk.27 Similarly, a 2009 cohort study of Australian MSM concluded that the use of nPEP was not associated with changes in HIV risk behavior.28 In a 2004 Brazilian cohort study of MSM, the use of nPEP also did not seem to be associated with increases in reported high-risk behavior; on the contrary, there was a slight decline in reported risk behavior in the cohort overall, and the frequent use of nPEP was not noted despite its ease of access made available by the study team.29 Furthermore, instances of repeat nPEP use by a single individual have not been attributed to behavioral disinhibition and increased risk behavior but instead to maintenance of the individual's baseline risk-taking behavior before nPEP use.25
Despite the evidence that nPEP is a safe and feasible method of HIV prevention, awareness of nPEP among the high-risk populations that would most benefit from its use, including MSM, remains low. Reported rates of nPEP awareness have been at its highest in California (47%),30 but a multicity study of minority, homosexual men attending gay pride parades found that only 21.4% of MSM were aware of the use of antiretroviral medication for HIV prevention.31 Factors strongly associated with nPEP knowledge in these studies included high numbers of reported sexual partners, HIV-positive serostatus, older age, and higher affluence. Most recently, a 2011 survey of MSM who engage in high-risk behavior at New York City bathhouses revealed that only 36% of respondents were aware of the use of antiretroviral medication to prevent disease transmission.32 Furthermore, knowledge was positively associated with respondents' disclosure of their MSM behaviors to their primary care physicians. Less than half of respondents overall (46.5%) had disclosed their high-risk behavior patterns to a health-care provider, despite high rates of primary care utilization (98.3%). These results underscore the importance of taking a sexual history as part of the medical history and clinical examination and the significant role that primary care providers can potentially play in expanding nPEP awareness and education among high-risk MSM by having a better understanding of patients' sexual practices.
Despite the CDC recommendations, few public health and primary care agencies have implemented nPEP promotion and practices. For example, a 2008 survey of New York state emergency room directors inquired about their knowledge of nPEP practices and protocols at their specific sites.33 Protocols had been developed for consensual sexual exposures at 59% of facilities, far less than for sexual assault exposures (95%). In regard to practice, patients presenting to the emergency room after a consensual exposure were significantly less likely to be given an nPEP prescription compared with victims of sexual assault. Because previous studies had shown that New York physicians offered nPEP after exposures of unknown risk more often than those from other states, this study likely overestimated nPEP practices, inferring that nPEP is even more underused nationwide.34 A 2011 cross-sectional survey of point-of-care health-care sites in Los Angeles County inquired about nPEP availability and found that just 14.5% of venues offered nPEP services, whereas only 8.5% offered services to uninsured and/or Medicaid patients.35 Of all venue types, including primary care clinics, HIV/infectious disease subspecialty care clinics, and community-based organizations offering HIV prevention services, hospital emergency departments were more than 5 times more likely to provide nPEP services.
To better inform ways in which the CDC and other governmental agencies can work with health departments to reduce new HIV infection, link individuals to HIV-related care and treatment, and facilitate a more collaborative national response to this epidemic, the CDC's Division of HIV/AIDS Prevention funded the 3-year demonstration project entitled “The Enhanced Comprehensive HIV Prevention Planning (ECHPP) Project.”36 The major aim of this project is to develop a plan in alignment with the National HIV/AIDS Strategy that maximizes the impact of HIV prevention strategies on reducing HIV incidence in 12 participating MSAs most affected by HIV/AIDS, including Miami and Washington, District of Columbia (DC). All these municipalities were chosen for having the highest prevalence of individuals living with HIV/AIDS and collectively represent 44% of the estimated AIDS cases nationwide. These goals include assessing the optimal combinations and impact of local prevention, care, and treatment approaches and the evaluation of current ECHPP implementation and utilization activities within these select jurisdictions to better inform the development of an optimal combination of behavioral, biomedical, and structural intervention activities to drive decision making and maximize impact on HIV prevention. Within this context, the University of Miami Miller School of Medicine and George Washington University ECHPP teams, along with the Miami-Dade County and DC health departments, developed a survey of HIV health-care providers as one of the many steps taken to address the implementation of HIV prevention planning strategies in these 2 MSAs and the CDC's ECHPP evaluation goals. Questionnaire items were developed to support each of the ECHPP study aims, including the aim to “investigate the availability, accessibility, and acceptability of prescribing and obtaining PEP by both HIV primary care providers and persons at high risk for HIV” in both Miami-Dade County and DC. Additionally, the DC ECHPP team, in collaboration with both the Miami and DC Developmental Centers for AIDS Research and the DC and Miami Department of Health HIV/AIDS, Hepatitis, STD, and TB Administration, sought to conduct preliminary analysis and review of existing nPEP policies and protocols and their applicability to the DC and Miami-Dade County, as part of an ECHPP demonstration project specific to nPEP feasibility, cost-effectiveness, and provision to populations at highest risk (ECHPP Strategy #4).
All study activities were approved by the Institutional Review Boards at George Washington University, DC Department of Health, University of Miami, and Columbia University.
Between March 2012 and March 2013, a survey was conducted of HIV providers in Miami-Dade County, Florida, and Washington, DC that focused on their knowledge, attitudes, beliefs, and practices related to the delivery of nPEP, preexposure prophylaxis (PrEP), and prevention and care issues with people living with HIV/AIDS.
Our target sample population consisted of infectious disease and HIV providers who had treated at least one HIV-positive patient in the year preceding the administration of the survey. We selected these providers as the target sample for this survey with the understanding that our findings would best represent providers who are at the forefront of HIV treatment and prevention strategies and should have the highest provision of nPEP as a method to prevent new infections. The majority of HIV providers in Miami and DC provide care to non–HIV-infected subjects as infectious disease specialists, sexually transmitted disease clinic providers, and/or primary care providers. In addition, because of the nature of their clinical practice, HIV providers tend to be more informed and up to date about current HIV guidelines, the use of antiretroviral medications, including dosing and side effects, and the required initial and follow-up medical workup of a person exposed to HIV. These characteristics explain why patients either self-refer themselves or are referred by their primary doctors or partners to an HIV provider in the event of a nonoccupational HIV exposure. Although any primary care physician can prescribe antiretroviral medication, infectious disease specialists or emergency physicians in most centers are responsible for nPEP,5 and government-sponsored Web sites, such as http://aids.gov/, recommend seeking nPEP at a private doctor's office, emergency room, urgent care clinics, or a local HIV clinic.37
A variety of sources were used in compiling the clinician lists for each city, including the American Academy of HIV Medicine, AIDS Education and Training Center, state Infectious Disease Society, Ryan White Part A and B programs, local Medicaid offices, health departments, and other local medical societies. This list represented more than 230 providers serving patients with HIV in community-based outpatient clinics/offices and outpatient clinics associated with large hospitals/medical centers.
The initial contact, which was done by mail in Miami and e-mail in DC, included a cover letter explaining the purpose of the study, information on how to complete the questionnaire, and the offer of a $20 incentive for completing the questionnaire. Names were not included with the questionnaire, and participants were informed that their responses would be confidential. Using a modified version of Dillman total design method38 for mail and telephone surveys, we continued to follow-up with respondents for 3 months using a variety of methods, including phone calls, e-mails, postcards, questionnaire remailings, and in-person visits (Miami only).
Providers were given the opportunity to complete the survey electronically through a secure, encrypted Internet connection using the Web-based program Survey Monkey (http://www.surveymonkey.com/; SurveyMonkey, Palo Alto, CA) for Miami-Dade respondents; the Research Electronic Data Capture (REDCap) program, a secure, Web-based application hosted at George Washington University designed to support data capture for research studies for the DC respondents; or on paper. Each survey took 15–20 minutes to complete. Questionnaire items were developed to support each of the ECHPP study aims, including the aim to investigate the availability, accessibility, and acceptability of prescribing and obtaining PEP by both HIV primary care providers and persons at high risk for HIV in both Miami-Dade County and DC.14,33,39,40
Merged Data Set, Sample Size, and Response Rate
Once recruitment activities concluded at both sites, the data sets from both cities were shared over a secure network and then aggregated. Analysis of the combined data sets was based on responses from 142 providers out of 231 identified practitioners practicing in these 2 major metropolitan areas, for a final response rate of 61%. The DC site had a sample size of 124 providers and received responses from 63 providers (response rate of 50.8%). The Miami site received responses from 79 out of a total of 107 identified providers, for a response rate of 73.8%.
We examined differences in survey responses by site and by history of prescribing nPEP using χ2 analysis. We examined any significant differences by history of prescribing nPEP for potential interaction or confounding by site using logistic regression analysis. Finally, we created a multivariable model of factors related to the history of prescribing nPEP by including all simple relationships with history of prescribing nPEP with a P value under 0.10 and using backward elimination. Because of different patterns for missing data across survey questions, we used multiple imputation.41 Because the independent variables were all categorical, we used a fully conditional specification for the imputation step.42,43 We used 20 imputed data sets to maximize statistical power.44
Most medical providers in the survey were over 40 years old and had more than 10 years of practice with the modal category for both sites being more than 20 years of practice (Table 1). There was a difference across sites in the racial/ethnic distribution with Miami having more Hispanic and fewer White providers. Miami (65.4%) also had more male providers than did DC (50.8%) though this was not statistically significant. The modal category of number of patients seen per month was more than 200 for both Miami (55.8%) and DC (45.2%), with most providers reporting more than 20 HIV-positive patients seen in the last 3 months at both sites.
TABLE 1-a Descriptiv...Image Tools
nPEP Experience and Knowledge
TABLE 1-b Descriptiv...Image Tools
TABLE 1-c Descriptiv...Image Tools
More providers in DC (59.7%) reported ever prescribing nPEP than providers in Miami [39.5%, χ2(1) = 6.09, P < 0.048]. The majority of practices in both cities did not have a written nPEP protocol and rarely or never had patients ask for nPEP. About a third of practices in the entire sample felt there were barriers to prescribing nPEP at their site. About 82% of providers at each site knew that the CDC has formal guidelines for the use of nPEP, and most (Miami 67.7%, DC 78.3%) knew that unprotected anal exposure is a higher risk factor for HIV than percutaneous occupational exposure. Substantially fewer providers knew (Miami 41.3%, DC 41.7%) that percutaneous occupational exposure is a higher risk than vaginal exposure.
Barriers and Facilitators to Prescribing nPEP
A large majority of providers felt that they were more likely to prescribe nPEP if a patient had an HIV+ partner (80.7%) or had been a victim of a sexual assault (79.0%). A much smaller proportion felt they were more likely to prescribe nPEP if a patient had a partner of unknown HIV status (26.5%) or if the patient had a history of no condom use (27.1%). There were significant differences in the impact of history of sexually transmitted infections and being a person who injected drugs on the likelihood of prescribing nPEP. Providers in Miami reported they were less likely to prescribe to a patient with a history of sexually transmitted infections than in DC [Miami 29.3% more likely, DC 45.9% more likely, χ2(4) = 15.04, P < 0.0039; for all categories of responses, Table 1]. Similarly, providers in Miami were less likely to prescribe nPEP to a person who injected drugs than were providers in DC [Miami 29.3% more likely, DC 54.1% more likely, χ2(4) = 16.93, P < 0.0020; for all categories of responses, Table 1]. Very few providers felt they would be likely to prescribe nPEP to patients with a history of irregular clinic visits (13.6%) or a history of nonadherence to medication (11.0%).
Attitudes Toward nPEP
Most providers agreed (80.3%) that it was possible to prescribe nPEP at their clinic; however, fewer providers in Miami, compared to DC, felt there was adequate time to prescribe nPEP [χ2(2) = 9.03, P < 0.0109]. About a third of providers at each site (Miami 37.3%, DC 31.2%) also felt there were barriers to prescribing nPEP at their facilities. Significantly more providers in Miami (40.5%) felt that nPEP will promote HIV resistance than did providers in DC [12.7%, χ2(2) = 15.38, P < 0.0005]. Similarly, significantly more providers in Miami (48.1%) than in DC (14.3%) felt that nPEP would promote risky behavior [χ2(2) = 18.13, P < 0.0001].
Bivariate Relationships With History of Prescribing nPEP
Medical providers who had prescribed nPEP were more likely to be associated with larger practices [χ2(4) = 9.96, P < 0.0411, Table 2]. Those in practices that care for more than 200 patients in a month were more likely to have prescribed nPEP than those in practices with fewer than 50 patients [odds ratio (OR) = 5.16, 95% confidence interval (CI): 1.51 to 17.67]. Providers in practices where more than 20 HIV-positive patients were seen in the past 3 months were more likely than those in practices with 20 or fewer HIV-positive patients seen to have prescribed nPEP (OR = 3.77, 95% CI: 1.38 to 10.32). Similarly, providers who themselves had seen more than 20 HIV-positive patients in the past 3 months were more likely to have prescribed nPEP (OR = 2.50, 95% CI: 1.12 to 5.61). Those practices with providers who had prescribed nPEP were also more likely to have a written nPEP protocol [χ2(2) = 6.17, P < 0.0456, Table 2]. Providers who did not know if their site had a written nPEP policy were less likely to have prescribed nPEP than those who did know that their site had a written nPEP policy (OR = 0.26, 95% CI: 0.72 to 0.97). Providers who had patients who requested nPEP were more likely to have prescribed nPEP than providers who did not have patients who requested nPEP (OR = 34.16, 95% CI: 11.68 to 102.58). Providers who had prescribed nPEP were more likely than those who had not prescribed nPEP to know that the CDC has formal guidelines for the use of nPEP [χ2(2) = 6.21, P < 0.0448]; however, this was no longer significant after controlling for site. Providers who believed nPEP provision was feasible in their practice were more likely than those who felt nPEP provision was not feasible to have prescribed nPEP [χ2(4) = 11.20, P < 0.0037]. Providers who had prescribed nPEP endorsed that they were more likely than those who had not prescribed nPEP to prescribe to patients who had a partner of unknown HIV status [χ2(4) = 10.32, P < 0.0353]. Additionally, providers who had prescribed nPEP were less likely than those who had not prescribed nPEP to believe that nPEP will promote antiretroviral resistance [χ2(2) = 31.01, P < 0.0001]. Those who believed nPEP would not create resistance were more likely to have prescribed nPEP than those who were neutral (OR = 3.17, 95% CI: 1.33 to 7.57) or those who felt nPEP would create antiretroviral resistance (OR = 13.66, 95% CI: 4.49 to 41.58). Finally, those providers who felt nPEP would not increase risk behavior were significantly more likely to have prescribed nPEP than those who felt that nPEP would increase risk behavior (OR = 6.49, 95% CI: 2.50 to 16.81).
Multivariate Model for History of Prescribing nPEP
Table 3 shows the initial multivariable model for history of prescribing nPEP, which was dominated by having patients who request nPEP [adjusted OR (aOR) = 21.53, 95% CI: 6.50 to 71.34] and provider belief that nPEP would lead to antiretroviral resistance (aOR = 0.14, 95% CI: 0.04 to 0.55). We reestimated the multivariate model excluding “having patients who request nPEP” as a predictor to examine other multivariable predictors related to practice and provider attitudes. In this model, belonging to a practice which saw more than 20 HIV-positive patients (aOR = 6.33, 95% CI: 1.94 to 20.67) and having a written protocol for nPEP (aOR = 7.49, 95% CI: 1.47 to 38.27) were both associated with higher odds of having prescribed nPEP. Reporting barriers to prescribing nPEP in a practice was associated with lower odds of having prescribed nPEP (aOR = 0.33, 95% CI: 0.13 to 0.83). Agreeing that nPEP may cause antiretroviral resistance was associated with much lower odds of having prescribed nPEP (aOR = 0.05, 95% CI: 0.02 to 0.19) and feeling neutral about the possibility of increased antiretroviral resistance was associated with lower odds of having prescribed nPEP (aOR = 0.22, 95% CI: 0.08 to 0.61), both relative to those who disagreed that nPEP would increase antiretroviral resistance.
This study of HIV providers' knowledge, attitudes, beliefs, and practices toward the use of nPEP was carried out in 2 US cities that have been disproportionately affected by the HIV/AIDS epidemic.45–47 Both are southern cities that have the highest rates of HIV/AIDS in the United States across populations of MSM, persons at risk for HIV through heterosexual transmission, and substance use.46–52 Both Miami and DC were included in the CDC-funded ECHPP project so that their local health departments, in collaboration with community leaders and key stakeholders, could develop a plan and enhance prevention strategies to reduce HIV incidence, increase access to HIV care for persons living with HIV, and decrease the HIV-related health disparities outlined in the National HIV/AIDS Strategy. Expanding use of nPEP was one of the suggested ECHPP HIV prevention strategies.
Study findings document low provision of nPEP by HIV providers participating in our survey. Less than half of HIV providers in Miami and a little more than half of HIV providers in DC have ever prescribed nPEP. Of unexpected note to the study team was the statistically significant difference in nPEP provision between the 2 major cities and the significant differences in attitudes related to nPEP. Given that both DC and Miami are 2 cities with high HIV prevalence selected for inclusion within ECHPP, we would expect to see similar nPEP provision and attitudes regarding nPEP between the 2 cities. Further exploration is warranted to assess city-specific differences in HIV prevention education, awareness, and policy to determine why nPEP practices and attitudes are not comparable between 2 heavily HIV-prevalent MSAs. Still, it is important to note that in both cities, there are few providers who promote the availability of nPEP services at their clinic. For example, throughout the city of DC, there is only one program funded by the DC Department of Health to provide nPEP to sexual assault victims.
Furthermore, because the providers sampled in our survey were the medical providers most likely to receive frequent referrals and requests for nPEP because of their expertise in HIV medicine, provision among non-HIV providers in these communities is most likely even lower. With respect to knowledge, approximately 20% of survey respondents were not aware of the CDC guidelines and less than half of the respondents were aware that percutaneous exposure carried greater risk than unprotected vaginal exposure. These findings were unanticipated given that, of all medical specialists, HIV providers should be well informed of relevant HIV guidelines, current prevention strategies, and transmission risks. Finally, with regard to practitioners' greatest concerns regarding nPEP, two of the top responses were behavioral disinhibition and cost, despite the body of evidence25–29 noted earlier that disproves these concerns. These findings also point out that providers, representing the group of individuals most responsible for the patients' health, there is a significant opportunity for education. In this regard, Web-based resources, in collaboration with AIDS Education and Training Centers, can be recruited to fill this educational need by assisting in providing accurate information regarding for whom nPEP use should be considered, the risks of using it, and resources to assist providers in how to deliver nPEP. Awareness of the opportunities and the potential barriers should be addressed at all layers of care, including prevention efforts in Department of Health facilities and education campaigns, urgent care centers, emergency rooms, and physician practices. With the ongoing changes in health-care reforms, it is clear that those providing care to individuals at risk for infection, be it an HIV specialist or primary care provider, must have the opportunities, knowledge, and tools to assist in making well-informed clinical decisions pertaining to HIV prevention.
Although the majority of HIV providers surveyed in this study indicated being aware of CDC guidelines regarding the use of nPEP, the majority of providers indicated that there were no written nPEP protocols in their clinics and that they had never received requests from patients to prescribe nPEP. Notably, having a written protocol and being asked by a patient to provide nPEP were among the factors that were most strongly related to nPEP provider prescribing behaviors. This finding speaks to the importance of subjective norms and how HIV providers' prevention practices are influenced both by demand from their patients and encouragement from their clinic administrators. The development and implementation of written protocols in clinics and hospitals nationwide will likely require collaboration at both the clinician level and the institutional administrative level to identify and address institutional barriers to nPEP provision.
Interventions that encourage patients to ask for prevention strategies that might work best for them should be developed and implemented. Recent efforts to enhance health literacy and to get patients to advocate for themselves have increasingly been recognized as an important prevention strategy. nPEP is not something that is currently offered to patients when appropriate. It follows that efforts to educate persons at risk for HIV about this underused prevention strategy and encourage them to initiate a dialogue with their provider about opportunities for potential interventions could improve clinical outcomes. For example, in DC, social marketing campaigns for routine HIV testing emphasized provider-initiated testing, but advertisements were also geared toward patients and empowering them to ask for the test. Also, Fenway Health (Boston, MA) has recently launched a TalkPEP.org campaign where they are seeking to raise awareness of PEP and encourage people to “talk PEP” with their social networks, partners, and providers.53 Furthermore, targeted education strategies need to be developed and implemented to raise generalized awareness and knowledge about the use of nPEP that will ideally help foster an ongoing dialogue within the patient–doctor relationship about HIV prevention.
Physician and patient awareness of the effectiveness of PrEP for MSM and women who are adherent to their medication regimens may also have a positive impact on the use of nPEP. Many of the previous concerns raised among clinicians regarding the use of nPEP, including patient nonadherence, pharmacological toxicities, high costs, and concerns about how use of nPEP could result in “behavioral disinhibition,” are also being raised about PrEP.15,18,19 There are several operational research studies underway to address many of these concerns related to PrEP and the impact of provider attitudes about nPEP on the acceptability and provision of PrEP and vice versa.54,55 As findings emerge, it is possible that clinicians will reevaluate concerns related to nPEP and PrEP and use the emergence of PrEP as an intervention approach to educate patients about nPEP as an important and underused biomedical HIV prevention strategy.54 Additionally, further research comparing provider attitudes and practices with respect to nPEP versus PrEP would be beneficial. Specifically, identifying how providers choose between the use of nPEP and PrEP in specified situations can play a pivotal role in prevention policy and protocols; for example, nPEP may be a more appropriate strategy in the case of sexual assault, but not for a patient involved in an ongoing serodiscordant partnership. Although both nPEP and PrEP were queried in this survey, the focus of this article was specific only to provider attitudes and practices related to nPEP.
Several limitations of our data should be noted. First, nonrespondents may have differed from respondents in terms of their reporting of prescribing practices. The small number of nonrespondents with available data limits the conclusions that can be made regarding nonresponse bias. Second, the data obtained were self-reported and not confirmed through patient interviews or clinical records. Third, there are small differences in the methods used between each city, such as the form of the initial contact and Miami's use of the Dillman total design method for follow-up communications, which may account for differences in study findings. Finally, our survey sampled HIV care providers with high volumes of HIV-positive patients practicing in Miami and Washington, DC; therefore, our findings may be of limited generalizability outside these 2 cities or other ECHPP MSAs with high HIV prevalence, among non-HIV providers, or among those with smaller patient volumes. Future studies assessing nPEP practices and attitudes may consider surveying other populations of medical providers, such as primary care physicians, who may not receive as many patient requests/referrals for nPEP or be as aware of current nPEP recommendations and/or advances in HIV medicine. This could help determine the population(s) of providers with the potential to make the most use of nPEP and to further target nPEP education and HIV prevention strategies accordingly.
Despite these limitations, our findings are consistent with previous studies that have shown the underuse of nPEP as a prevention strategy. HIV prevention researchers worldwide are recognizing the need for a combination HIV prevention approach that takes advantage of multiple HIV prevention strategies, and nPEP is a strategy that has been shown to be both effective and cost effective.10,11,24,25 Given the recent publication of trials showing the efficacy of PrEP, it may be the right time to renew efforts to increase use of nPEP and to develop strategies to support its successful implementation.
2. Baeten JM, Donnell D, Ndase P, et al.. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367:399–410.
3. Grant R, Lama J, Anderson P, et al.. Pre-exposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363:2587–2599.
4. Thigpen M, Kebaabetswe P, Paxton L, et al.. Antiretroviral pre-exposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med. 2012;367:423–434.
5. Tissot F, Erard V, Dang T, et al.. Non-occupational HIV post-exposure prophylaxis: a 10-year retrospective analysis. HIV Med. 2010;11:584–592.
6. Otten R, Smith D, Adams D, et al.. Efficacy of post-exposure prophylaxis after intravaginal exposure of pig-tailed macaques to a human-derived retrovirus (human immunodeficiency virus type 2). J Virol. 2000;74:9771–9775.
7. Tsai C, Emau P, Follis K, et al.. Effectiveness of post-inoculation (R)-9-(2-phosphonylmethoxypropyl) adenine treatment for prevention of persistent simian immunodeficiency virus SIVmne infection depends critically on timing of initiation and duration of treatment. J Virol. 1998;72:4265–4273.
8. Mori K, Yasutomi Y, Sawada S, et al.. Suppression of acute viremia by short-term post-exposure prophylaxis of simian/human immunodeficiency virus SHIV-RT-infected monkeys with a novel reverse transcriptase inhibitor (GW420867) allows for development of potent antiviral immune responses resulting in efficient containment of infection. J Virol. 2000;74:5747–5753.
9. Sperling R, Shapiro D, Coombs R, et al.. Maternal viral load, zidovudine treatment, and the risk of transmission of human immunodeficiency virus type 1 from mother to infant. N Engl J Med. 1996;335:1621–1629.
10. Cardo D, Culver D, Ciesielski C, et al.. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. N Engl J Med. 1997;337:1485–1490.
11. Centers for Disease Control and Prevention. Case-control study of HIV seroconversion in health-care workers after percutaneous exposure to HIV-infected blood—France, United Kingdom, and United States, January 1994-August 1994. MMWR Morb Mortal Wkly Rep. 1995;444:929–933.
12. Katzenstein T, Dickmeiss E, Aladdin H, et al.. Failure to develop HIV infection after receipt of HIV-contaminated blood and post-exposure prophylaxis. Ann Intern Med. 2000;133:31–34.
13. Bloch M, Carr A, Vasak E, et al.. The use of human immunodeficiency virus post-exposure prophylaxis after successful artificial insemination. Am J Obstet Gynecol. 1999;181:760–761.
14. Kunches L, Meehan T, Boutwell R, et al.. Survey of non-occupational HIV post-exposure prophylaxis in hospital emergency departments. J Acquir Immune Defic Syndr. 2001;26:263–265.
15. Centers for Disease Control and Prevention. Antiretroviral post-exposure prophylaxis after sexual, injection-drug use, or other non-occupational exposure to HIV in the United States. MMWR Recomm Rep. 2005;54:1–20.
16. Merchant R, Becker B, Mayer K, et al.. Emergency department blood or body fluid exposure evaluations and HIV post-exposure prophylaxis usage. Acad Emerg Med. 2003;10:1345–1353.
17. Shoptaw S, Rotheram-Fuller E, Landovitz RJ, et al.. Non-occupational post-exposure prophylaxis as a biobehavioral HIV-prevention intervention. AIDS Care. 2008;20:376–381.
18. Lurie P, Miller S, Hecht F, et al.. Post-exposure prophylaxis after non-occupational HIV exposure. JAMA. 1998;280:1769–1773.
19. Richens J, Edwards S, Sadiq S. Can the promotion of post-exposure prophylaxis following sexual exposure to HIV (PEPSE) cause harm? Sex Transm Infect. 2005;81:190–191.
20. Kahn J, Martin J, Roland M, et al.. Feasibility of post-exposure prophylaxis (PEP) against human immunodeficiency virus infection after sexual or injection drug use exposure: the San Francisco PEP study. J Infect Dis. 2001;183:707–714.
21. Low-Beer S, Weber A, Bartholomew K, et al.. A reality check: the cost of making post-exposure prophylaxis available to gay and bisexual men at high sexual risk. AIDS. 2000;14:325–326.
22. Pinkerton S, Holtgrave D, Bloom F. Cost-effectiveness of post-exposure prophylaxis following sexual exposure to HIV. AIDS. 1998;12:1067–1078.
23. Spence J. Should emergency departments offer post-exposure prophylaxis for non-occupational exposure to HIV? CJEM. 2003;5:38–45.
24. Pinkerton S, Martin J, Roland M, et al.. Cost-effectiveness of HIV post-exposure prophylaxis following sexual or injection drug exposure in 96 metropolitan areas in the United States. AIDS. 2004;18:2065–2073.
25. Martin JN, Roland ME, Neilands TB, et al.. Use of post-exposure prophylaxis against HIV infection following sexual exposure does not lead to increases in high-risk behaviour. AIDS. 2004;18:787–792.
26. Mayer K, Mimiaga M, Cohen D, et al.. Tenofovir DF plus lamivudine or emtricitabine for non-occupational post-exposure prophylaxis (NPEP) in a Boston community health center. J Acquir Immune Defic Syndr. 2008;47:494–499.
27. Donnell D, Mimiaga M, Mayer K, et al.. Use of non-occupational post-exposure prophylaxis does not lead to an increase in high risk sex behaviors in men who have sex with men participating in the EXPLORE trial. AIDS Behav. 2010;14:1182–1189.
28. Poynten I, Jin F, Mao L, et al.. Non-occupational post-exposure prophylaxis, subsequent risk behaviour and HIV incidence in a cohort of Australian homosexual men. AIDS. 2009;23:1119–1126.
29. Schechter M, Do Lago RF, Mendelsohn AB, et al.. Behavioral impact, acceptability, and HIV incidence among homosexual men with access to post-exposure chemoprophylaxis for HIV. J Acquir Immune Defic Syndr. 2004;35:519–525.
30. Liu A, Kittredge P, Vittinghoff E, et al.. Limited knowledge and use of HIV post- and pre-exposure prophylaxis among gay and bisexual men. J Acquir Immune Defic Syndr. 2008;47:241–247.
31. Voetsch A, Heffelfinger J, Begley E, et al.. Knowledge and use of pre-exposure and post exposure prophylaxis among attendees of minority gay pride events, 2005 through 2006. J Acquir Immune Defic Syndr. 2007;46:378–380.
32. Mehta SA, Silvera R, Bernstein K, et al.. Awareness of post-exposure HIV prophylaxis in high-risk men who have sex with men in New York City. Sex Transm Infect. 2011;87:344–347.
33. Ende A, Hein L, Sottolano D, et al.. Non-occupational post-exposure prophylaxis for exposure to HIV in New York state emergency departments. AIDS Patient Care STDs. 2008;22:797–802.
34. Merchant R, Keshavarz R. Emergency prophylaxis following needle-stick injuries and sexual exposures: results from a survey comparing New York emergency department practitioners with their national colleagues. Mt Sinai J Med. 2003;70:338.
35. Landovitz RJ, Combs K, Currier J. Availability of HIV post exposure prophylaxis services in Los Angeles County. Clin Infect Dis. 2009;48:1624–1627.
38. Dillman D. Mail and Telephone Surveys: The Total Design Method. New York, NY: John Wiley & Sons Inc; 1978.
39. McCausland J, Linden J, Degutis L, et al.. Non-occupational post-exposure HIV prevention: emergency physicians' current practices, attitudes, and beliefs. Ann Emerg Med. 2003;42:651–656.
40. Merchant R, Keshavarz R. HIV post-exposure prophylaxis practices by US ED practitioners. Ann Emerg Med. 2003;21:309–312.
41. Enders C. Applied Missing Data Analysis. New York, NY: The Guilford Press; 2010.
42. van Buuren S. Multiple imputation of discrete and continuous data by fully conditional specification. Stat Methods Med Res. 2007;16:219–242.
43. van Buuren S, Brand JPL, Groothuis-Oudshoorn CGM, et al.. Fully conditional specification in multiple imputation. J Stat Comput Simul. 2006;76:1049–1064.
44. Graham J, Olchowski AE, Gilreath T. How many imputations are really needed? Some practical clarifications of multiple imputation theory. Prev Sci. 2007;8:206–213.
45. Lalota M, Beck D, Metsch L, et al.. HIV seropositivity and correlates of infection among heterosexually active adults in high-risk areas in South Florida. AIDS Behav. 2011;15:1259–1263.
46. Magnus M, Kuo I, Shelley K, et al.. Risk factors driving the emergence of a generalized heterosexual HIV epidemic in Washington, District of Columbia networks at risk. AIDS. 2009;23:1277–1284.
47. Magnus M, Kuo I, Phillips G, et al.. Elevated HIV prevalence despite lower rates of sexual risk behaviors among black men in the District of Columbia who have sex with men. AIDS Patient Care STDS. 2010;24:615–622.
52. Magnus M, Kuo K, Phillips G, et al.. Differing HIV risks and prevention needs among men and women injection drug users (IDU) in the District of Columbia. J Urban Health. 2013;90:157–166.
54. Cahill S. Policy Focus: Pre-exposure Prophylaxis for HIV Prevention: Moving Toward Implementation. 2nd ed. Boston, MA: The Fenway Institute; 2012.
55. Underhill K, Operario D, Skeer M, et al.. Packaging PrEP to prevent HIV: an integrated framework to plan for pre-exposure prophylaxis implementation in clinical practice. J Acquir Immune Defic Syndr. 2010;55:8–13.
nonoccupational exposure; antiretroviral prophylaxis; HIV prevention; HIV medical providers
© 2013 by Lippincott Williams & Wilkins
Highlight selected keywords in the article text.