PrEP Scripts Most Likely to Be Filled When Prescribed by ID Specialists

Primary care practitioners (PCPs) provided the majority of prescriptions for HIV preexposure prophylaxis (PrEP) in the U.S., but the odds of patients filling a PrEP prescription were better when it came from an infectious disease (ID) specialist, according to a cross-sectional study.

Among adults at risk for HIV who received a prescription for PrEP, adjusted analyses showed that those with an initial prescription from an ID specialist had a 10% lower odds of reversal (OR 0.90, 95% CI 0.81-0.99) and a 12% lower odds of abandonment (OR 0.88, 95% CI 0.78-0.98) compared with prescriptions from PCPs, reported Lorraine Dean, ScD, of Johns Hopkins Bloomberg School of Public Health in Baltimore, and colleagues.

Of the 37,003 adults receiving a prescription in the study, 67% received their initial prescription from a PCP, 10% received one from an ID specialist, and 24% received a prescription from another specialist clinician.

“The study results suggest that PCPs are an important initial access point for PrEP, given that they do the bulk of PrEP prescribing,” the study authors wrote in JAMA Internal Medicine.

However, nearly 20% of all PrEP prescriptions across all providers were never filled (i.e., prescription reversal) — a key measure of nonadherence. And 14% of prescriptions were abandoned, meaning they were not filled after a year.

That reversals and abandonments were less likely with an ID specialist may reflect some self-selection in the cohort, Dean suggested.

“Many times, patients see a primary care physician and then are referred to an infectious disease physician,” she told MedPage Today. “The patients who take the time to then follow-up with an [ID] specialist may be most motivated and able to follow through with the specialist’s request, in this case, accessing their PrEP prescription.”

Another explanation for the suboptimal reversal and abandonment rates among PCP-written prescriptions could be that “PCPs often tackle a multitude of issues in their clinics and may not have enough time or resources to provide counseling and ongoing support around PrEP,” Meredith Greene, MD, of the Indiana University School of Medicine in Indianapolis, and JAMA Internal Medicine‘s associate editor Lona Mody, MD, MSc, of the VA Ann Arbor Healthcare System in Michigan, wrote in an accompanying editorial.

Of note, the risks of prescription reversal and abandonment were even worse when the prescription came from other specialist clinicians, reaching 33% higher odds of reversal (OR 1.33, 95% CI 1.25-1.41) and 54% higher odds of abandonment (OR 1.54, 95% CI 1.44-1.65) when compared with prescriptions from PCPs.

Clinicians other than PCPs and ID specialists included advanced practice clinicians of unspecified specialties, as well as clinicians in emergency medicine, women’s health, and others.

“For other specialty clinicians, PrEP may not be the primary focus of the visit and their clinics may not have the structural supports to counsel and follow up patients taking PrEP,” the editorialists wrote.

“What was most surprising was how many other providers are involved in PrEP care — and it’s a good thing that so many providers are engaged in prescribing a medication that’s so effective,” Dean pointed out. “Our results suggest that a wide range of prescribers, regardless of specialty, should be equipped to prescribe PrEP as well as offer PrEP counseling.”

“Previous studies have shown that emergency medicine clinicians and ob/gyn clinicians are similarly uncomfortable with their lack of PrEP content knowledge, uncertainty around referrals, and/or time-related barriers to discussing PrEP,” the study authors added. “General PrEP training … is important to improve PrEP care.”

Their report was based on prescription data from 2015 to 2019, when oral tenofovir disoproxil fumarate/emtricitabine (Truvada) was the only FDA-approved PrEP medication available.

Since then, oral emtricitabine/tenofovir alafenamide (Descovy) was approved as PrEP, as has long-acting injectable cabotegravir (Apretude) — the first option for HIV PrEP that does not involve taking a daily pill.

For their NIH-funded study, Dean and colleagues relied on pharmacy claims data capturing 80% to 85% of all U.S. PrEP prescription claims. Researchers matched these records with clinician data from the U.S. National Plan and Provider Enumeration System.

Overall, the highest percentage of new PrEP claims was among patients ages 25 to 34 years, accounting for 36% of all prescriptions. Most recipients of PrEP prescriptions were men.

ID clinicians in the study were more likely to prescribe PrEP to people from high-risk HIV groups, such as patients ages 18 to 24 years, those who are Black and/or Hispanic, and patients with incomes of $30,000 per year or less. In contrast, patients who received prescriptions from PCPs were more likely to be men, non-Hispanic, and have an income of $100,000 or more. They were also more likely to have commercial insurance and an associate’s degree or higher.

Patients who received PrEP from other specialist clinicians were more likely to be women, Medicaid recipients, and be of other/unknown race.

The observed absolute differences between prescriber specialties and prescription reversal and abandonment rates was fairly small, the study authors noted.

Of patients who were initially prescribed PrEP by PCPs, 18% failed to pick up their initial prescription from the pharmacy. Of those prescribed PrEP by ID specialists, prescription reversal was also 18%, but rose to 25% among patients who received a prescription from other specialist clinicians. Twelve percent of prescriptions from PCPs, 12% from ID specialists, and 20% from other clinicians were abandoned.

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