Roadblocks to PrEP: What Medical Records Reveal About Access to HIV Pre-exposure Prophylaxis
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Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center Bedford, Bedford, MA, USA; University Health Services, University of Massachusetts, Amherst, MA, USA; 3Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA; 4Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA; 5Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA; 6 Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCVAMC), Cleveland, OH, USA; 7Department of Internal Medicine, Case Western School of Medicine, Cleveland, OH, USA. 2
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
Presentations An earlier version of this manuscript was presented for a symposium at the VA HSR&D National Conference in Washington DC in 2017. Received May 7, 2019 Accepted October 2, 2019
barriers can inform organizational interventions to increase PrEP access and decrease HIV transmission. KEY WORDS: HIV/AIDS; prevention; pre-exposure prophylaxis; patient
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