by MICHAELA FLEMING
It has been demonstrated that pre-exposure prophylaxis (PrEP) is efficacious in preventing HIV and recent efforts have focused on increasing uptake among ideal candidates.
In a new investigation, published in the Journal of General Internal Medicine, a team of investigators set out to study barriers that may affect patients seeking a PrEP prescription in Veterans Health Administration (VHA) settings.
One common barrier to PrEP uptake is the high price tag, but in the VHA setting there are fewer cost barriers than there are associated with commercial insurance. Therefore, the investigators set out to evaluate other barriers that may inhibit PrEP uptake.
In order to do so, the investigators extracted descriptive information from electronic medical records and conducted a qualitative analysis of all PrEP-relevant notes. The team collected information including whether the PrEP conversation was provider or patient-initiated, time to interval between request and prescription, reasons for PrEP denial, and patient responses to barriers. Information was collected from 161 patients who were prescribed PrEP at 90 VHA sites, with varying PrEP prescribing rates. Read more via Contagion
Skolnik, Avy A., et al. "Roadblocks to PrEP: What Medical Records Reveal About Access to HIV Pre-exposure Prophylaxis." Journal of general internal medicine (2019): 1-7.
Background
Pre-exposure prophylaxis (PrEP) has been shown to be efficacious in preventing HIV; however, its uptake remains modest. Given that there are fewer cost barriers to receiving PrEP within VHA than via commercial insurance, VHA represents an ideal setting in which to study other barriers that may impact patients seeking PrEP.
Objective
We sought to understand potential barriers to obtaining PrEP within the Veterans Health Administration (VHA) through examination of documentation in electronic medical records.
Design
Retrospective structured chart review, including chart abstractions of notes, referrals, and communications; content analysis of charts from a subsample of patients receiving PrEP in VHA.
Participants
One hundred sixty-one patients prescribed PrEP at 90 sites varying in PrEP prescribing rates.
Approach
We extracted descriptive information and conducted a qualitative analysis of all PrEP-relevant free-text notes including who initiated the PrEP conversation (patient vs. provider), time interval between request and prescription, reasons for denying PrEP, and patient responses to barriers.
Key Results
Patients initiated 94% of PrEP conversations and 35% of patients experienced delays receiving PrEP ranging from six weeks to 16 months. Over 70% of cases evidenced barriers to access. Barriers included provider knowledge gaps about PrEP, provider knowledge gaps about VHA systems related to PrEP, confusion or disagreement over clinic purview for PrEP, and provider attitudes or stigma associated with patients seeking PrEP.
Conclusions
Although PrEP is recommended for HIV prevention in high-risk persons, many PrEP-eligible individuals faced barriers to obtaining a prescription. Current practices place substantial responsibility on patients to request and advocate for this service, in contrast to many other preventive services. Understanding the prevalence and content of PrEP knowledge gaps and attitudinal barriers can inform organizational interventions to increase PrEP access and decrease HIV transmission.