HIV Post-Exposure Prophylaxis (PEP) Awareness and Non-Occupational PEP (nPEP) Prescribing History Among U.S. Healthcare Providers

Factors Influencing Oral Pre-, Post-, and Doxycycline Post-Exposure Prophylaxis Uptake Among Substance-Using Men Who Have Sex with Men in the Rural Southern US

Substance-using men who have sex with men (MSM), especially those in rural areas, face a heightened risk of HIV and sexually transmitted infections (STIs). Despite increased risk, uptake of HIV pre-exposure prophylaxis (PrEP), HIV post-exposure prophylaxis (PEP), and doxycycline post-exposure prophylaxis (Doxy-PEP) remains low among rural MSM. The multi-domain factors influencing past-year use of oral PrEP, PEP, and Doxy-PEP among substance-using MSM in the rural southern US remain unknown. A cross-sectional study of rural substance-using MSM (n = 345) in the Southern US was conducted from February 29 to March 23, 2024. Three series of bivariate and multivariate logistic regression analyses were conducted. Past-year PrEP use was significantly associated with HIV-negative status (adjusted odds ratio [aOR] = 2.55, 95% confidence interval [CI]: 1.12-5.80, p = 0.025), past-year STI diagnosis (aOR = 2.23, 95% CI: 1.19-4.15, p = 0.012), past-year HIV testing (aOR = 3.40, 95% CI: 1.05-10.9, p = 0.040), and past-year STI testing (aOR = 10.09, 95% CI: 2.25-45.37, p = 0.003). Past-year PEP use was significantly associated with past-year STI diagnosis (aOR = 3.70, 95% CI: 1.33-10.32, p = 0.012) and oral sex (aOR = 0.09, 95% CI: 0.01-0.63, p = 0.015). Finally, past-year Doxy-PEP use was significantly associated with past year-STI diagnosis (aOR = 4.44, 95% CI: 2.03-9.71, p < 0.001). Results underscore the need for integrated care across primary care, pharmacy, and substance use treatment settings to improve screening, education, and prescription of HIV/STI preventative biomedical pharmaceuticals for substance-using MSM.

Physician Attitudes Towards Pharmacist-Prescribed HIV Post-Exposure Prophylaxis (PEP): A Survey of a State Medical Association

Timely initiation of antiretroviral therapy (ART) for non-occupational post-exposure prophylaxis (nPEP) is crucial in preventing HIV infection and advancing efforts to end the HIV epidemic (EHE). nPEP must be administered within 72 h of high-risk exposure, ideally within 24 h. Pharmacies may play a role in increasing access to nPEP and facilitating referrals for additional care, such as PrEP. Recent legislation permits pharmacist-prescribed nPEP (PDP), though provider attitudes toward this change have not been studied. A survey querying physicians and medical trainees (students and residents) was conducted in 2024 during an annual state medical association conference. The survey included 24 questions on nPEP knowledge and attitudes towards pharmacist-prescribed nPEP (PDP). The survey was administered in person using electronic tablets, with voluntary participation incentivized by a monetary reward. Statistical analysis was conducted using SAS (9.4 version) software, with differences in responses between physicians and trainees evaluated. P values < 0.05 were considered statistically significant. Of 89 respondents (56% of attendees), 61 were physicians and 28 were trainees. Notably, 28% of licensed providers indicated that pharmacist-directed prescribing (PDP) should not be allowed in the State of Ohio, while no trainees expressed this same opposition (p = 0.001). Trainees were more likely to view pharmacist prescribing as safe and appropriate ((p = 0.0135, p = 0.013). Urban-based providers were more supportive of pharmacist prescribing than their rural counterparts (p = 0.0195). Trainees showed little opposition to PDP, whereas physicians expressed concerns about safety and appropriateness. Addressing these concerns is essential for integrating pharmacists into the EHE strategy.

Assessing Knowledge, Practices, and Barriers to PrEP and nPEP Prescription Among Texas Healthcare Providers

BACKGROUND

The effectiveness of pre-exposure prophylaxis (PrEP) and non-occupational post-exposure prophylaxis (nPEP) in preventing HIV is well-established, yet their use in clinical practice remains low. Healthcare providers, especially those in primary and emergency care settings, play a crucial role in adopting and implementing these prevention strategies. We conducted a statewide survey with 519 healthcare providers in Texas to assess their knowledge, practices, and barriers related to prescribing PrEP and nPEP.

METHODS

The survey collected data on demographics, clinical experience, practice type, awareness of recommended guidelines, knowledge of PrEP and nPEP, prescribing practices, and challenges encountered to prescribe these medications. We used multiple regression analysis to identify factors associated with PrEP and nPEP prescribing behavior.

RESULTS

While most providers were familiar with CDC and/or USPSTF-recommended PrEP guidelines, fewer had adequate knowledge of nPEP. Key challenges identified by providers included concerns about cost (48%), limited time (40% for PrEP and 51% for nPEP), and insufficient education or training (40% for PrEP and 35% for nPEP). Providers who were more familiar with the recommended guidelines and had greater experience in sexual health assessment were more likely to prescribe both PrEP and nPEP.

CONCLUSIONS

This study highlights the need for enhanced education and training to boost providers' knowledge and confidence in prescribing PrEP and nPEP. It also underscores the importance of addressing cost-related barriers and simplifying care processes to better integrate these HIV prevention strategies into primary and emergency care settings.

Missed Opportunities: A Narrative Review on Why Nonoccupational Postexposure Prophylaxis for HIV Is Underutilized

Postexposure prophylaxis (PEP) is an important tool for preventing HIV infection but remains underutilized. In this narrative review, we aim to summarize the frequency of missed opportunities for prescribing PEP among studies from around the world, discuss the complexities of the challenges facing PEP provision, and describe possible solutions. We identified 20 studies published in the last 10 years among 43 832 individuals, of whom an estimated 41 477 were eligible for PEP. Of those eligible for PEP, PEP was prescribed among 27 705 (66.8%). There was a significant difference in PEP prescriptions in acute compared with non-acute care settings (63.5% vs 94.5%; P < .001). Emergent themes contributing to PEP underutilization included lack of provider and patient awareness, reduced PEP acceptability, HIV stigma and homophobia, lack of access (either to care or to medication), and stigmatizing policies. Each of those issues should be the focus of future PEP implementation efforts.

Longitudinal predictors of post-exposure prophylaxis awareness among latino sexual minority men in South Florida

Biomedical tools for HIV prevention such as post-exposure prophylaxis (PEP) continue to be underutilized by subgroups experiencing significant HIV inequities. Specifically, factors associated with both PEP awareness and uptake both cross-sectionally and longitudinally are under-researched, despite PEP being a part of the United States' Plan for Ending the HIV Epidemic. The current study examined longitudinal predictors of PEP awareness among Latino sexual minority men (LSMM) living in South Florida. This current study (N = 290) employed hierarchal linear modeling across three timepoints (baseline, 4-months, 8-months) to assess within-person and between-person effects over time for several psychosocial and structural factors. Most participants (67.5%) reported little to no awareness of PEP at baseline with general PEP awareness growing slightly across the study (60.5% reporting little to no awareness of PEP at 8 months). Results of the final conditional model suggest significant within-person effects of PrEP knowledge (p = 0.02) and PrEP self-efficacy (p < 0.001), as well as a significant positive between-person effect of PrEP knowledge (p < 0.01) on PEP awareness. Between-person HIV knowledge was also a significant predictor in this model (p = 0.01). This longitudinal analysis of LSMM's PEP awareness indicates that more must be done to increase PEP awareness among this subgroup. Future studies should explore how to build on existing interventions focused on HIV and PrEP knowledge and PrEP self-efficacy to incorporate information about PEP to increase the reach of this effective biomedical HIV prevention tool.

Navigating Barriers and Opportunities: Perceptions of the Non-Occupational Post-Exposure Prophylaxis Care Continuum Among Young Sexual Minority Men, Aged 17-24, in the United States

Human immunodeficiency virus (HIV) is a public health concern among young sexual minority men (YSMM), ages 17 to 24, in the United States. Biomedical prevention methods, such as pre-exposure prophylaxis (PrEP) and non-occupational post-exposure prophylaxis (nPEP), can help reduce the risk of HIV transmission among this population. However, there is limited awareness and use of nPEP by YSMM. This study aims to explore the perceptions of YSMM regarding the nPEP care continuum, which consists of three areas of focus: awareness, uptake, and linkage to other HIV prevention services. This study draws on synchronous online focus groups with a sample of 41 YSMM in the United States. Transcripts from the focus groups were analyzed using reflexive thematic analysis. Participants reported limited nPEP awareness and prior use, a process of personal appraisal of nPEP need based on HIV risk and costs, and a preference for PrEP over PEP for long-term HIV prevention. Interventions should be tailored to increase awareness of nPEP among YSMM and reduce addressable barriers to nPEP use for YSMM, including cost and confidentiality concerns, in situations where nPEP is warranted. Finally, more research is needed on how nPEP use can act as a bridge to PrEP initiation for this population.

Expanding expedited partner therapy and HIV prophylaxis in the emergency department

PURPOSE

Sexually transmitted infections (STIs) continue to have a disproportionate impact on individuals belonging to sexual, gender, and racial minorities. Across the nation, many emergency medicine pharmacists (EMPs) possess the skills and knowledge to expand the provision of expedited partner therapy (EPT) for STIs and provide HIV prophylaxis within existing practice frameworks. This report serves as a call to action for expanded provision of EPT and HIV prophylaxis by EMPs and highlights current barriers and solutions to increase pharmacist involvement in these practice areas.

SUMMARY

Emergency medicine pharmacy practice continues to expand to allow for limited prescribing authority through collaborative practice agreements (CPAs). In recent years, CPA restrictions have been changed to facilitate treatment of more patients with less bureaucracy. This report addresses the unique challenges and opportunities for expanding EPT and HIV pre- and postexposure prophylaxis provision by pharmacists in emergency departments (EDs). Furthermore, current strategies and treatments for EPT, such as patient-delivered partner therapy and HIV prophylaxis, are discussed. Pharmacist involvement in STI treatment and HIV prevention is a key strategy to increase access to high-risk populations with high ED utilization and help close current gaps in care.

CONCLUSION

Expanding EMP provision of EPT and HIV prophylaxis may be beneficial to reducing the incidence of STIs and HIV infection in the community. CPAs offer a feasible solution to increase pharmacist involvement in the provision of these treatments. Legislative efforts to expand pharmacist scope of practice can also contribute to increasing access to EPT and HIV prophylaxis. With these efforts, EMPs can play an essential role in the fight against STIs and HIV.

The Role of Community Pharmacies in Providing Access to HIV Post-exposure Prophylaxis (PEP)

HIV affects an estimated 1.2 million individuals in the United States and is disproportionately concentrated among African Americans, Latinos, and people of multiple races. Post-exposure prophylaxis (PEP) substantially decreases HIV transmission when started within 72 h after exposure, but problems of accessibility have hindered its widespread usage in communities at risk for HIV infection. Pharmacy-initiated PEP access was first permitted in New York City in 2017, allowing pharmacists to provide a 7-day supply of PEP without a prescription for consumers at high risk for HIV infection. It was expected that the broad reach and accessibility of community pharmacies would increase timely access to PEP for all individuals, especially those who already face significant barriers to accessing the healthcare system. Since then, eleven other states have followed suit and expanded the scope of outpatient pharmacy practice in order to increase the availability of HIV PEP but prescribing laws in over 75% of the US have not been changed. Much of the existing literature on HIV prevention focuses on PrEP access barriers with limited information on PEP access in the US. In this paper, we review the current status of pharmacist-initiated PEP in the US as part of the End the HIV Epidemic (EHE) initiative.

Analysis of HIV drug prophylaxis services cascade in healthcare workers: a cross-sectional study in China

BACKGROUND

Human immunodeficiency virus (HIV) drug prophylaxis, including post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP), has not yet been generally recognized and accepted by the whole society in China, and the utilization coverage among high-risk populations is low. Healthcare workers (HCWs) are important to the promotion and implementation of HIV drug prophylaxis strategy. This study analyzed the HIV drug prophylaxis services cascade (knowledge, attitude, and service) in HCWs, and explored the correlations between PEP and PrEP.

METHODS

A cross-sectional study was conducted among 1066 HCWs in 20 designated hospitals for HIV antiretroviral therapy in 20 cities in China. We collected information on participants' essential characteristics, HIV drug prophylaxis services cascade (knowledge, attitude, and service) and so on. The Chi-square test was used to analyse whether the differences and correlations between categorical variables were statistically significant, and Pearson contingency coefficient was used to analyse the strength of correlations. Multivariable logistic regression was used to analyse associated factors.

RESULTS

Among three stages of HIV drug prophylaxis services cascade, a high percentage of 1066 participants had knowledge of HIV drug prophylaxis (PEP: 78.2%, PrEP: 80.0%). Of them, almost all had supportive attitudes towards HIV drug prophylaxis (PEP: 99.6%, PrEP: 98.6%). Only about half of them would provide HIV drug prophylaxis services (PEP: 53.5%, PrEP: 48.5%). There were positive correlations between knowledge of PEP and PrEP (r = 0.292), between attitudes toward PEP and PrEP (r = 0.325), and between provision of PEP services and PrEP services (r = 0.555) in HCWs.

CONCLUSIONS

There was a positive correlation between PEP and PrEP in HCWs. At the stage of providing HIV drug prophylaxis services, training, advocacy and education for HCWs, should be targeted and also combine PEP and PrEP to maximize the effects, so as to improve the enthusiasm of HCWs to provide HIV drug prophylaxis services.

Sex Conservatism, Internalized Homonegativity, PrEP Stigma, and Intention to Use PrEP: A Study of Chinese-Speaking Gay and Bisexual Male Youth in Hong Kong

Pre-exposure prophylaxis (PrEP) stigma has been found to be a major barrier to PrEP acceptability and uptake. Research has found that different ethnic/cultural groups display varying levels of PrEP stigma. This article studies sex conservatism and internalized homonegativity as two sexuality- and culture-related aspects that influence PrEP stigma and intention to use PrEP. An online survey of 279 young gay and bisexual men in Hong Kong found that internalized homonegativity was positively associated with PrEP stigma. Respondents who were more conservative about sex showed lower intention to use PrEP, whereas those who had higher income and more positive attitudes about PrEP were more likely to express intention to use PrEP. This study provides novel empirical evidence for understanding PrEP stigma and uptake from a sexuality and cultural perspective. The influence of sexuality- and culture-related factors on PrEP stigma and uptake warrants greater attention, especially in the Asia-Pacific region.

Evidence of Potential Discriminatory HIV Pre-Exposure Prophylaxis (PrEP) Prescribing Practices for People Who Inject Drugs Among a Small Percentage of Providers in the U.S

INTRODUCTION

A large percentage of people who inject drugs (PWID) are living with HIV. Yet, rates of HIV pre-exposure prophylaxis (PrEP) use among PWID remain low. Stigma surrounding substance use and PWID have been identified as potential barriers to PrEP. This study examined healthcare providers' concerns regarding PWID and willingness to prescribe PrEP to PWID.

METHODS

An online, cross-sectional survey of a diverse group of healthcare providers in the 10 U.S. cities with the greatest HIV prevalence was conducted between July 2014 and May 2015. Participants responded to a patient vignette of a PWID and asked to indicate whether the patient would be a candidate for PrEP and why via free-response text. Descriptive statistics are reported using frequency measures. Bivariate analyses were conducted using chi-squared comparisons and logistical regression.

RESULTS

Survey data from 480 providers were included in analyses. Of the 480 responses, 85.5% were classified as PrEP aware, while 14.2% were PrEP unaware. Additionally, 82.6% indicated the patient would be a good candidate for PrEP, 4.4% believed the patient was not a good candidate for PrEP, and 13% were unsure. Among those who were unsure or would not prescribe PrEP (n = 84), open-ended responses indicated lack of knowledge (42.9%), concern about adherence (27.4%), concern about cost (4.8%), and bias (7.1%) as the primary reasons.

CONCLUSIONS

Although the majority of providers in this study did not demonstrate bias against PWID, our study found that limited PrEP knowledge and bias are barriers to PrEP prescription among PWID for some providers. Interventions are needed that increase PrEP awareness of CDC guidelines and reduce implicit bias among providers.

Tailored HIV Pre-exposure Prophylaxis (PrEP) Intervention Needs from a Latent Class Analysis Among U.S. Healthcare Providers

Interventions are needed to expand HIV pre-exposure prophylaxis (PrEP) prescribing practices among healthcare providers, but research classifying providers to determine tailored intervention needs is lacking. Providers reported demographics, factors related to HIV treatment and prevention experience, and PrEP-related factors such as knowledge and community protection beliefs via online survey. Latent class analysis grouped providers with similar patterns of HIV prevention- and treatment-related care and tested for associations with demographics and PrEP-related factors. Three distinct classes of providers emerged: (1) PrEP naïve, (2) PrEP aware, and (3) PrEP prescribers. Providers with lower community protection beliefs and staff capacity were more likely to be classified as PrEP naïve compared to aware (ps < 0.05). Providers with concerns about PrEP-related tasks and staff capacity were more likely to be classified as PrEP aware compared to prescribers (ps < 0.05). PrEP-naïve providers could benefit from continuing education, whereas PrEP-aware providers might benefit from capacity building and prescribing optimization interventions.

Context and Barriers to the Prescription of Nonoccupational Postexposure Prophylaxis Among HIV Medical Care Providers: National Internet-Based Observational Study in China

BACKGROUND

Nonoccupational postexposure prophylaxis (nPEP) is an effective HIV biomedical prevention strategy. The research and use of nPEP are mainly concentrated in the developed world, while little is known about the knowledge, attitudes, and practices of nPEP among HIV medical care providers in developing countries.

OBJECTIVE

We aimed to assess the nPEP knowledge and prescribing practice among HIV medical care providers in mainland China.

METHODS

HIV medical care providers were recruited in China during May and June 2019 through an online survey regarding nPEP-related knowledge, attitudes, and clinical prescription experiences. Multivariable logistic regression was performed to identify factors associated with prescribing nPEP among HIV medical care providers.

RESULTS

A total of 777 eligible participants participated in this study from 133 cities in 31 provinces in China. Of the participants, 60.2% (468/777) were unfamiliar with nPEP and only 53.3% (414/777) of participants ever prescribed nPEP. HIV care providers who worked in a specialized infectious disease hospital (vs general hospital, adjusted odds ratio [aOR] 2.49; 95% CI 1.85-3.37), had practiced for 6-10 years (vs 5 or fewer years, aOR 3.28; 95% CI 2.23-4.80), had practiced for 11 years or more (vs 5 or fewer years, aOR 3.75; 95% CI 2.59-5.45), and had previously prescribed occupational PEP (oPEP, aOR 4.90; 95% CI 3.29-7.29) had a significantly positive association with prescribing nPEP. However, unfamiliarity with nPEP (aOR 0.08; 95% CI 0.05-0.11), believing nPEP may promote HIV high-risk behavior (aOR 0.53; 95% CI 0.36-0.77) or result in HIV drug resistance (aOR 0.53; 95% CI 0.36-0.77) among key populations, and self-reported having no written oPEP guideline in place (aOR 0.53; 95% CI 0.35-0.79) were negatively associated with nPEP prescription behavior.

CONCLUSIONS

HIV medical care providers have insufficient nPEP knowledge and an inadequate proportion of prescribing, which may impede the scale-up of nPEP services to curb HIV acquisition. The implementation of tailored nPEP training or retraining to HIV medical care providers would improve this situation.