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Roadblocks to PrEP: What Medical Records Reveal About Access to HIV Pre-exposure Prophylaxis

  • Avy A. SkolnikEmail author
  • Barbara G. Bokhour
  • Allen L. Gifford
  • Brigid M. Wilson
  • Puja Van Epps
Original Research

Abstract

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.

KEY WORDS

HIV/AIDS prevention pre-exposure prophylaxis patient-provider communication primary care 

Notes

Funding Information

Dr. Van Epps is supported by the Geriatric Research Education and Clinical Center (GRECC). Additionally, Dr. Skolnik was funded by a VHA post-doctoral research fellowship.

Compliance with Ethical Standards

Conflict of Interest

No conflict of interest, financial or other, exists for any of the authors of this manuscript.

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Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  1. 1.Center for Healthcare Organization and Implementation Research (CHOIR)ENRM Veterans Affairs Medical Center BedfordBedfordUSA
  2. 2.University Health ServicesUniversity of MassachusettsAmherstUSA
  3. 3.Department of Health Law, Policy, and ManagementBoston University School of Public HealthBostonUSA
  4. 4.Section of General Internal Medicine, Department of MedicineBoston University School of MedicineBostonUSA
  5. 5.Center for Healthcare Organization and Implementation Research (CHOIR)VA Boston Healthcare SystemBostonUSA
  6. 6.Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCVAMC)ClevelandUSA
  7. 7.Department of Internal MedicineCase Western School of MedicineClevelandUSA

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