Provider Knowledge Gaps in HIV PrEP Affect Practice Patterns in the US Navy

Abstract

Introduction

Although HIV pre-exposure prophylaxis (PrEP) is available at no cost to personnel in the United States (U.S.) military, uptake has been lower than expected. An online survey was conducted assessing current knowledge, perceptions, and attitudes of primary care providers in the U.S. Navy.

Materials and Methods

A cross-sectional anonymous online survey was conducted among U.S. Navy healthcare providers in active service. Providers’ demographics, medical practice and PrEP experience, and attitudes regarding PrEP were assessed by self-rated PrEP knowledge.

Results

Greater than half of respondents reported being knowledgeable about PrEP and a majority (78%) supported the provision of PrEP in the military health system. However, only 19% had ever prescribed PrEP. Self-reports of having been questioned by a patient about PrEP, having high levels of comfort discussing sexual risk behaviors, and being in a specialty of infectious disease, occupational health, or preventive medicine were associated with increased knowledge about PrEP. The more knowledgeable a provider was about PrEP, the more likely they were to prescribe it (29% vs. 6%).

Conclusions

Although Navy providers were supportive of the provision of PrEP by the military, knowledge gaps remain. Training to address the knowledge deficit as well as improving sexual history taking are potential areas to target in implementing PrEP in primary care specialties.

INTRODUCTION

Although incidence of HIV infection has declined overall over the past few years in the United States (U.S.), the majority of new infections continue to be acquired by men who have sex with men.¹ This has led to increased demand for effective prevention measures in high-risk populations. In 2012, the U.S. Food and Drug Administration (FDA) approved the HIV antiretroviral drug emtricitabine/tenofovir disporoxil fumarate (Truvada) as pre-exposure prophylaxis (PrEP) for adults at high risk for sexually acquired HIV infection.² Several studies have supported this approval and demonstrate that both PrEP adherence as well as a comprehensive preventive approach (providing risk reduction measures and counseling, conducting regular HIV and sexually transmitted infection (STI) testing, etc.) serve to greatly reduce the risk of HIV acquisition.^3,4 In May 2014, the U.S. Public Health Service (USPHS), in concert with the Centers for Disease Control and Prevention (CDC), released the first comprehensive clinical guidelines for PrEP that provide criteria for determining a person’s HIV risk and indications for PrEP use. These guidelines, which were updated in 2017, establish requirements for ensuring patients are HIV negative prior to starting PrEP, have regular monitoring for HIV infection and STI testing, as well as assessment for side effects and adherence to PrEP. In addition, the guidelines discuss the need for continued evaluation of ongoing risk of HIV acquisition and ensuring risk reduction counseling at regular intervals.

With the repeal of Don’t Ask Don’t Tell (DADT) policy in September 2011, an increasing number of men who have sex with men (MSM), bisexual, and HIV-serodiscordant couples are openly accessing medical care within the Department of Defense (DoD).^5,6 These patients represent a population at high risk for HIV acquisition. Despite the ability to seek open, honest medical care, and the no-cost access to Truvada, uptake throughout the Navy has been slower than expected compared to some civilian practices.⁵ The nuance of the military mission often poses challenges to adhering to nationally prescribed guidelines. Service members frequently relocate or are unable to maintain regular follow up appointments due to specific military duties. Maintaining fitness for duty may be a deterrent to uptake. Both the Air Force and Navy require a waiver for use of Truvada for HIV PrEP for pilots and air crew members as does United States Central Command (USCENTCOM or CENTCOM) for deployment into its Area of Responsibility (AOR).^7–9 The relative contribution of patient versus provider factors attributable to slow uptake of PrEP remains unclear. We felt it was important to assess providers’ knowledge, perceptions, and views regarding the use of PrEP, to determine if there was an effect on service members’ access to this medication, and/or the quality of care received. There has been documented controversy in the literature regarding how to apply the data in clinical practice, as well as questions such as the cost-effectiveness, side effects of using medications in previously healthy patients, and concerns for resistance.^10,11 In addition, there are specific military concerns when using these medications, such as appropriate management of PrEP during deployments. We conducted a voluntary, anonymous assessment to gauge comprehension of the current literature and available data, as well as attitudes regarding applicability of HIV PrEP. By doing so, we aimed to better define the current and anticipated prescribing practices, as well as characterize the consensus opinion or lack thereof amongst Navy providers.

METHODS

Study Population and Distribution

In March 2017, Navy providers in active service were invited via email to take part in an online needs assessment survey. At the end of the survey, respondents were offered a $10 Amazon card as compensation for their time. The link to the survey was available for two weeks during which non-responders received up to three reminder emails to generate higher response rates. The surveyed population was intended to capture all providers who may prescribe PrEP, including infectious disease, family medicine, internal medicine, occupational health, preventive medicine, and pediatrics. Mailing lists for physicians, physician assistants, advance practice registered nurses, registered nurses and independent duty corpsmen were obtained from the specialty leaders within each department. Registered nurses and independent duty corpsmen were included in the mailing list since they are allowed to prescribe PrEP in the Navy with higher authorization.

The needs assessment was conducted as a part of a quality improvement project that was reviewed and approved as non-human subject research by the Walter Reed National Military Medical Center (OPNAV RCS 6200–3), and the Walter Reed Army Institute of Research’s Division of Human Subjects Protection Office (#2374). The survey data was collected in a de-identified manner. Those surveyed were informed that participation was voluntary, and that their responses were entirely anonymous.

Survey

The survey consisted of 22 yes-no, Likert-type, and multiple-choice questions adapted from an Air Force survey for Navy service-specific considerations.¹² Survey questions assessed provider demographics (3 questions), knowledge in prescribing PrEP (3 questions), their clinical practice patterns (7 questions), and their perceptions and beliefs regarding how/when it should be used (9 questions). Knowledge-based questions were based on CDC clinical practice guidelines, and elicited responses to drug-combination approved for PrEP and clinical evaluation and monitoring practices recommended for PrEP.¹³ The survey ended with links to online web resources on HIV PrEP and HIV treatment.

Data Management and Analysis

For undeliverable emails and lists that consisted only of provider names without associated email addresses, two staff members searched a U.S. military web directory for alternate email addresses. The two email lists were compared and corrected for accuracy and added to a single master list, which was used to resend email invitations. Reminders were sent to respondents who had a valid email address and had not redeemed a gift card.

Participants’ demographics, medical practice and experience prescribing PrEP, and attitudes toward and knowledge of PrEP were described, as well as providers’ self-rated knowledge regarding PrEP. The relationship of demographic and medical practice characteristics with self-rated knowledge was evaluated in univariate analysis using Chi-square and logistic regression; providers rating their PrEP knowledge as sufficient, good, or excellent were considered PrEP “knowledgeable” and were then compared to those with a self-rating of poor knowledge who were considered “not [PrEP] knowledgeable”. Multivariate logistic regression was used to assess characteristics independently associated with self-rated PrEP knowledge by adjusting for other variables of significance (p < 0.25).¹⁴ Additionally, provider attitudes, beliefs, and concerns were described overall and by self-rated level of PrEP knowledge and subsequently compared for differences using Chi-square. Locations of current medical practice were collapsed into five regions: Northeast, Midwest, Southern, Western U.S., and outside the continental United States (OCONUS). Experience in prescribing PrEP was derived from a question regarding practice in prescribing antiretroviral medications for: HIV post-exposure prophylaxis (PEP), non-occupational PEP (nPEP), and PrEP. Correct responses to questions regarding FDA-approval medication for PrEP and CDC guidance regarding PrEP were given a score of 1 point for a possible total score of 7 points (Table S1). The calculated knowledge score was highly correlated with self-rated knowledge (p < 0.05) and therefore was not included in regression analysis. Five-point Likert-type responses were collapsed into 3 categories in analysis. Data management and analysis were conducted using Statistical Analysis Software version 9.4 (SAS Cary, NC).

RESULTS

Provider Demographics and Practice Patterns

Of the 1,258 providers eligible for participation, 441 (35%) participated in the survey. Nine respondents were excluded for lack of completion of the survey. Among the final analytic sample (n = 432), respondents averaged 42.1 years of age (range: 30.0–72.0). Most were physicians (89%), male (64%), had not provided HIV care in the last year (52%), and primarily specialized in family practice (34%) with only 5% specializing in infectious disease. Almost half (48%) practiced in Southern U.S. states at the time of taking the survey and had spent an average of 11.9 years (range: 0.0–40.0) in practice as a licensed provider (Table I). Nearly half (49%) saw up to 100 patients per month and reported being asked by patients about PrEP (48%). However, only 19% of all respondents had ever prescribed PrEP. A higher percentage (37%) reported some experience prescribing antiretroviral medications for HIV post-exposure prevention (Table I). Most providers rated their knowledge as Poor (41%, n = 178) or Sufficient (31%, n = 135) whereas only about 1 in 4 providers rated their knowledge as Good (17.1%, n = 74) or Excellent (6.9%, n = 30). Providers knowledgeable about PrEP were more likely to prescribe PrEP (29%) compared to providers who reported poor knowledge (6%) (Table I); the most common indications for prescribing PrEP were patient request (25%) followed by having a male patient who reported having receptive anal sex with men (23%) (Table S2).

Nine demographic and practice characteristics were associated with self-rated knowledge in univariate analysis (p < 0.25, Table I): sex, provider type, primary specialty, comfort discussing sexual risk history with patients, frequency of taking a sexual history, number of patients in practice treated for HIV infection, ever prescribing antiretrovirals for HIV prevention, ever being questioned by a patient about HIV PrEP, and frequency in prescribing HIV PrEP in the last 12 months. Three factors were independently associated with having self-reported PrEP knowledge (p < 0.05) after adjustment for confounding for the other six variables of significance in univariate analysis (p < 0.25): having ever been questioned by a patient about PrEP (OR, 3.86; 95% CI, 2.35–6.33), having an infectious disease/occupational health/preventive medicine primary specialty compared to other specialties (OR, 3.03; 95% CI, 1.61–5.66), and indicating comfort discussing sexual risk behaviors with patients (OR, 2.70, 95% CI, 1.47–4.93) (Table II).

Knowledge

Self-rated knowledge was found to be highly correlated with calculated knowledge score. Providers who indicated that they were well-informed about PrEP scored significantly higher on questions regarding CDC guidelines compared to providers who thought they were poorly knowledgeable (mean knowledge score, 4.9 vs 1.7, respectively, p < 0.001) (Table I). Whereas 81% of providers with poor self-rated knowledge were “not sure” of which medication was FDA-approved for PrEP, 74% of knowledgeable providers answered correctly (Table S1).

Provider Beliefs and Attitudes About PrEP

Provider beliefs and attitudes varied by self-rated knowledge about PrEP. Compared to providers who reported being knowledgeable about PrEP, providers who were not knowledgeable were more frequently unsure about whether using Truvada as PrEP would select for antiretroviral resistance (62% vs 47%, p = 0.001), and whether PrEP was feasible financially (“PrEP is too costly”: 52% vs 31%, p = < 0.001) (Fig 1A). Furthermore, these providers indicated significantly more discomfort prescribing drugs for new indications unless there was clear evidence (55% vs 42%, p = 0.001). Conversely, providers who reported being knowledgeable about PrEP commonly disagreed with statements about not having time to engage in provision of PrEP (73% vs 43%, p < 0.001), not having patients at risk for HIV (79% vs 64%, p = 0.003), and PrEP being only for serodiscordant couples (81% vs 54%, p < 0.001; Fig. 1B). Overall, provider support for provision of PrEP in the military health system was high (76%) especially among knowledgeable providers (83% vs 73%, p = 0.01; Fig. 1B).

Furthermore, support for providing PrEP to at-risk patients was high (78%), although compared to knowledgeable providers, providers who were not knowledgeable were more uncertain (25% vs 10%) and slightly less supportive (72% vs 88%) (Table III). When asked to rate the likelihood of prescribing PrEP under eight circumstances (Fig. S1), knowledgeable providers were more likely to prescribe PrEP in higher HIV transmission risk scenarios. An overwhelming majority (94%) of providers indicated they would benefit from learning about PrEP. Over half of providers, irrespective of self-rated PrEP knowledge, specified that continuing medical education or workshops (72%), online learning modules (54%) and access to papers from peer-reviewed journals (51%) were the most useful training media for learning about PrEP (Table III). Regardless of self-rated knowledge levels, a majority (79%) indicated they would benefit from a DoD clinical practice guideline for PrEP in the military, and supported continuation of PrEP on deployment, sea duty and overseas assignments (61%).

DISCUSSION

In our assessment of knowledge and attitudes about PrEP among Navy providers delivering care to military personnel and their beneficiaries located nationwide and overseas, more than half reported being knowledgeable about PrEP and a majority supported the provision of PrEP in the military health system and to at-risk patients. However, only one fifth had ever prescribed PrEP. Self-reports of having ever been questioned by a patient about PrEP, having high levels of comfort discussing sexual risk behaviors with patients, and being in a primary specialty of infectious disease, occupational health, or preventive medicine were associated independently with self-rated knowledgeability about PrEP. Additionally, the more knowledgeable a provider was about PrEP, the more likely they were to support its use and to prescribe it.

Navy providers were almost twice as likely to report having ever prescribed PrEP (19%) compared to reports by Air Force providers (9%) in a 2015 survey and reports by Army providers who had ever prescribed PrEP (11% of 754 respondents) in a survey conducted 6 months earlier (unpublished data).¹² Since our assessment was conducted almost five years after FDA approval of Truvada for use in HIV PrEP, and three years after issuance of PrEP guidance by the CDC, the comparative higher prescribing pattern may be due to temporal trends reflecting increased uptake nationally from 2013 to 2015.^15,16 This is comparable to civilian data nationwide, as 4–35% of primary care providers surveyed from 2014–2015 reported having prescribed PrEP.^17–19

As with civilian providers, Navy providers also shared potential barriers of inexperience, uncertainties regarding logistics (e.g., cost, time constraints) and medication (perceived lack of evidence, effectiveness), and correctly identifying appropriate candidates for PrEP.^17,20,21 These potential barriers to prescribing PrEP may be surmountable by increased experience and training and reduction of structural barriers in implementing PrEP in the military.⁵ Training delivered as a webinar or face-to-face has been shown to increase provider comfort in taking a sexual history and improve HIV/STD screening.²² This survey data demonstrates that knowledgeable providers, whose practice characteristics suggested specialty training, comfort with sexual history taking, and having patients enquire about PrEP, did not share similar uncertainties or concerns. Whereas reported uptake of PrEP in the DoD (17%) has been almost twice that seen nationally (approximately 8%), barriers in the military health system may play a role in limiting uptake of PrEP.^5,23 The medication (Truvada) and all recommended laboratory tests for PrEP are not universally available across the smaller medical treatment centers in the military. Furthermore, at the major medical treatment facilities, prescription of PrEP has been traditionally restricted to infectious disease providers. Despite these barriers, most Navy providers supported the provision of PrEP in the military health system and endorsed the need for guidelines on implementing PrEP in the military. Interestingly, almost two-thirds of providers supported continuation of PrEP while away on assignments such as deployments, sea and overseas duties – despite the inability for timely follow up that this would entail. Recent procedural guidance released by the Defense Health Agency in November 2018 on provision of PrEP in the military may lead to remarkable progress in overcoming provider concerns and increased uptake by service members most in need of PrEP.²⁴

One clear limitation of this study is that it is subject to participation bias; providers who responded may have been more interested in HIV prevention such as PrEP than non-responders. We attempted to accommodate for this by providing a gift card incentive. Additionally, our surveyed population was limited to military providers (not civilian and contract personnel working in military health centers), which may limit generalizability. Lastly, the 22-question survey was lengthy and could potentially introduce information bias due to survey-fatigue. We had a response rate of 35%, which is comparable to the Air Force and Army surveys.

CONCLUSIONS

Navy providers were highly supportive of the provision of PrEP by the military and issuance of a military-specific clinical practice guidance. However, knowledge gaps remain, which seem to limit applicability in practice. More training to address the knowledge deficit regarding PrEP and improvement in sexual history taking are potential areas to target in implementing PrEP in primary care specialties. Continuing medical education workshops were identified as the most useful education tool.

ACKNOWLEDGMENTS

The authors wish to thank Ms. Elizabeth Bianchi and Ms. Erifile Zografos for their assistance in data extraction and quality control.

FUNDING

This study was supported by the U.S. Army Medical Research and Materiel Command under Contract No W81XWH-16-C-0225 and by a cooperative agreement (W81XWH-11-2-0174) between The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF), and the U.S. Department of Defense (DoD). The authors thank Dr. Kayvon Modjarrad, Director, Emerging Infectious Disease Branch and Dr. Robert Gramzinski, Director, U.S. Military HIV Research Program for general programmatic support.

CONFLICT OF INTEREST

Lt Col Jason Okulicz reports personal fees from Gilead Sciences not related to the submitted work. No other conflicts of interest were reported.

The authors are military service members or government contractor employees. This work was prepared as part of official duties. Title 17, U.S.C., §105 provides that copyright protection under this title is not available for any work of the U.S. Government. Title 17, U.S.C., §101 defines a U.S. Government work as a work prepared by a military Service member or employee of the U.S. Government as part of that person’s official duties.

The identification of specific products or scientific instrumentation does not constitute endorsement or implied endorsement on the part of the author, DoD, or any component agency. The views expressed in this presentation are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.

References