Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin, Milwaukee, Wisconsin.
AIDS Patient Care STDS. 2020 Mar;34(3):111-123. doi: 10.1089/apc.2019.0189. Epub 2020 Feb 28.
Increasing prescription of pre-exposure prophylaxis (PrEP) is imperative to ending the HIV epidemic in the United States. The objective of this review was to identify health care provider barriers to PrEP implementation. A systematic review was conducted in February 2019 using PubMed to identify barriers to PrEP prescribing practices in the United States. Targeted search terms surrounding PrEP and providers resulted in 222 original studies, 28 of which were ultimately included in our review, with data collected between 2011 and 2018. Six themes were identified across reviewed studies: (i) a lack of PrEP knowledge, (ii) the presence of the Purview Paradox, which refers to discordance in beliefs between HIV specialists and primary care providers on who should prescribe PrEP, (iii) concerns about PrEP costs, (iv) concerns about behavioral and health consequences, (v) interpersonal stigma, and (vi) concerns about patient adherence. A majority of providers were lacking knowledge regarding PrEP, resulting in discomfort in prescribing PrEP, or limited awareness and understanding of PrEP clinical guidelines. Discrepant opinions were identified regarding whether PrEP was best managed within primary care or specialty clinics. Other barriers included concerns about cost, patient adherence, and follow-up maintenance care. Finally, concerns about risk compensation and discomfort discussing sexual activities with patients who would benefit most from PrEP were apparent. Additional work is needed to prepare providers to prescribe and manage patients on PrEP, optimize PrEP delivery, and reduce provider bias. Future research is needed to identify providers' attitudes and beliefs regarding innovations in PrEP dosing, task shifting, and novel strategies for PrEP care.
增加暴露前预防（PrEP）的处方量对于结束美国的艾滋病疫情至关重要。本研究旨在确定医疗保健提供者在实施 PrEP 方面的障碍。2019 年 2 月，我们通过 PubMed 进行了一项系统评价，以确定美国 PrEP 处方实践的障碍。围绕 PrEP 和提供者的有针对性的搜索词导致了 222 项原始研究，其中 28 项最终被纳入我们的综述，数据收集时间为 2011 年至 2018 年。在综述研究中确定了六个主题：（i）缺乏 PrEP 知识，（ii）存在 Purview 悖论，这是指 HIV 专家和初级保健提供者在谁应该开 PrEP 方面的信念不一致，（iii）对 PrEP 成本的担忧，（iv）对行为和健康后果的担忧，（v）人际污名，以及（vi）对患者依从性的担忧。大多数提供者缺乏关于 PrEP 的知识，导致在开 PrEP 时感到不适，或者对 PrEP 临床指南的认识和理解有限。对于 PrEP 是最好在初级保健还是专科诊所管理存在意见分歧。其他障碍包括对成本、患者依从性和后续维持性护理的担忧。最后，人们对风险补偿和与最需要 PrEP 的患者讨论性活动的不适表示关注。需要做更多的工作来培训提供者开处方和管理接受 PrEP 的患者，优化 PrEP 的提供，并减少提供者的偏见。需要进一步的研究来确定提供者对 PrEP 剂量、任务转移和 PrEP 护理新策略的创新的态度和信念。
