AIDS and Behavior

, Volume 21, Issue 4, pp 1025–1033 | Cite as

Primary Care Physicians’ Willingness to Prescribe HIV Pre-exposure Prophylaxis for People who Inject Drugs

  • E. Jennifer EdelmanEmail author
  • Brent A. Moore
  • Sarah K. Calabrese
  • Gail Berkenblit
  • Chinazo Cunningham
  • Viraj Patel
  • Karran Phillips
  • Jeanette M. Tetrault
  • Minesh Shah
  • David A. Fiellin
  • Oni Blackstock
Original Paper


Pre-exposure prophylaxis for HIV (PrEP) is recommended for people who inject drugs (PWID). Despite their central role in disease prevention, willingness to prescribe PrEP to PWID among primary care physicians (PCPs) is largely understudied. We conducted an online survey (April–May 2015) of members of a society for academic general internists regarding PrEP. Among 250 respondents, 74% (n = 185) of PCPs reported high willingness to prescribe PrEP to PWID. PCPs were more likely to report high willingness to prescribe PrEP to all other HIV risk groups (p’s < 0.03 for all pair comparisons). Compared with PCPs delivering care to more HIV-infected clinic patients, PCPs delivering care to fewer HIV-infected patients were more likely to report low willingness to prescribe PrEP to PWID (Odds Ratio [95% CI] = 6.38 [1.48–27.47]). PCP and practice characteristics were not otherwise associated with low willingness to prescribe PrEP to PWID. Interventions to improve PCPs’ willingness to prescribe PrEP to PWID are needed.


HIV prevention Pre-exposure prophylaxis Attitude of health personnel Substance abuse 


Se recomienda la profilaxis previa a la exposición al VIH (PrEP) para las personas que se inyectan drogas (PWID). A pesar de su papel central en la prevención de enfermedades, la voluntad de prescribir la PrEP a PWID entre los médicos de atención primaria (PCP) es en gran parte poco estudiada. Realizamos una encuesta en línea (abril–mayo de 2015) de miembros de una sociedad para internistas académicos generales con respecto a la PrEP. Entre los 250 encuestados, el 74% (n = 185) de PCP informó de una gran disposición a prescribir PrEP a PWID. Los PCP mostraron mayor probabilidad de prescribir PrEP a todos los demás grupos de riesgo de VIH (p < 0,03 para todas las comparaciones de parejas). En comparación con los PCP que prestaban atención a más pacientes con infección por el VIH, los PCP que proporcionaban atención a menos pacientes infectados con VIH tenían más probabilidades de notificar una baja predisposición a prescribir PrEP a PWID (Odds Ratio [IC 95%] = 6,38 [1,48–27,47]). PCP y las características de la práctica no se asociaron de otra manera con baja voluntad de prescribir PrEP a PWID. Se necesitan intervenciones para mejorar la disposición de los PCP a prescribir la PrEP a PWID.


Prevención del VIH Profilaxis previa a la exposición Actitud del personal de salud Abuso de sustancias 



We would like to thank Ms. Katz for her assistance with programming the survey. A version of this work was presented as a poster presentation at the College on Problems of Drug Dependence Annual Meeting, June 16th, 2016 in Palm Springs, California.


This work was generously supported by Yale Center for Clinical Investigation (UL1 TR000142). EJ Edelman was supported as a Yale Drug Abuse, Addiction and HIV Research Scholars (DAHRS) Program during the writing of this manuscript (K12DA033312-03). BA Moore is supported by R01 DA034678. SK Calabrese is supported by K01-MH103080. O Blackstock is supported by K23MH102129-03.

Compliance with Ethical Standards

Conflicts of interest

Dr. Fiellin has received honoraria from Pinney Associates for serving on an external advisory board monitoring the diversion and abuse of buprenorphine. The authors have no other conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was reviewed and considered exempt by both Yale University and Albert Einstein College of Medicine’s Humans Investigation Committees.

Informed consent

Informed consent was obtained from all individual participants.


  1. 1.
    Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet. 2008;372(9651):1733–45.CrossRefPubMedGoogle Scholar
  2. 2.
    Strathdee SA, Stockman JK. Epidemiology of HIV among injecting and non-injecting drug users: current trends and implications for interventions. Curr HIV/AIDS Rep. 2010;7(2):99–106.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Centers for Disease Control and Prevention. Estimated HIV incidence in the United States, 2007–2010. 2012, Dec 2012 Report No.Google Scholar
  4. 4.
    MacArthur GJ, van Velzen E, Palmateer N, Kimber J, Pharris A, Hope V, et al. Interventions to prevent HIV and hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. Int J Drug Policy. 2014;25(1):34–52.CrossRefPubMedGoogle Scholar
  5. 5.
    Gowing L, Farrell MF, Bornemann R, Sullivan LE, Ali R. Oral substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev. 2011. doi: 10.1002/14651858.CD004145.pub4.PubMedGoogle Scholar
  6. 6.
    Des Jarlais DC, Kerr T, Carrieri P, Feelemyer J, Arasteh K. HIV infection among persons who inject drugs: ending old epidemics and addressing new outbreaks. AIDS. 2016;30(6):815–26.CrossRefPubMedGoogle Scholar
  7. 7.
    WHO, UNODC, UNAIDS Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users. 2012 RevisionGoogle Scholar
  8. 8.
    Escudero DJ, Lurie MN, Kerr T, Howe CJ, Marshall BD. HIV pre-exposure prophylaxis for people who inject drugs: a review of current results and an agenda for future research. J Int AIDS Soc. 2014;17:18899.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Choopanya K, Martin M, Suntharasamai P, Sangkum U, Mock PA, Leethochawalit M, et al. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet. 2013;381(9883):2083–90.CrossRefPubMedGoogle Scholar
  10. 10.
    Martin M, Vanichseni S, Suntharasamai P, Sangkum U, Mock PA, Leethochawalit M, et al. The impact of adherence to preexposure prophylaxis on the risk of HIV infection among people who inject drugs. AIDS. 2015;29(7):819–24.CrossRefPubMedGoogle Scholar
  11. 11.
    US Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States—2014: A clinical practice guideline. 2014.Google Scholar
  12. 12.
    Loughlin A, Metsch L, Gardner L, Anderson-Mahoney P, Barrigan M, Strathdee S. Provider barriers to prescribing HAART to medically-eligible HIV-infected drug users. AIDS Care. 2004;16(4):485–500.CrossRefPubMedGoogle Scholar
  13. 13.
    Smith DK, Van Handel M, Wolitski RJ, Stryker JE, Hall HI, Prejean J, et al. Vital signs: estimated percentages and numbers of adults with indications for preexposure prophylaxis to prevent HIV acquisition—United States, 2015. MMWR Morb Mortal Wkly Rep. 2015;64(46):1291–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Underhill K, Operario D, Mimiaga MJ, Skeer MR, Mayer KH. Implementation science of pre-exposure prophylaxis: preparing for public use. Curr HIV/AIDS Rep. 2010;7(4):210–9.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Stein M, Thurmond P, Bailey G. Willingness to use HIV pre-exposure prophylaxis among opiate users. AIDS Behav. 2014;18(9):1694–700.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Escudero DJ, Kerr T, Wood E, Nguyen P, Lurie MN, Sued O, et al. Acceptability of HIV pre-exposure prophylaxis (PREP) among people who inject drugs (PWID) in a canadian setting. AIDS Behav. 2015;19(5):752–7.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Krakower DS, Beekmann SE, Polgreen PM, Mayer KH. Diffusion of newer HIV prevention innovations: variable practices of frontline infectious diseases physicians. Clin Infect Dis. 2016;62(1):99–105.CrossRefPubMedGoogle Scholar
  18. 18.
    Castel AD, Feaster DJ, Tang W, Willis S, Jordan H, Villamizar K, et al. Understanding HIV care provider attitudes regarding intentions to prescribe PrEP. J Acquir Immune Defic Syndr. 2015;70(5):520–8.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Adams LM, Balderson BH. HIV providers’ likelihood to prescribe pre-exposure prophylaxis (PrEP) for HIV prevention differs by patient type: a short report. AIDS Care. 2016;28(9):1–5.CrossRefGoogle Scholar
  20. 20.
    The Henry J. Kaiser Family Foundation. Primary care physicians by field [5.14.2016]. 2016. Available from:
  21. 21.
    Artenie AA, Jutras-Aswad D, Roy E, Zang G, Bamvita JM, Levesque A, et al. Visits to primary care physicians among persons who inject drugs at high risk of hepatitis C virus infection: room for improvement. J Viral Hepat. 2015;22(10):792–9.CrossRefPubMedGoogle Scholar
  22. 22.
    Krakower D, Ware N, Mitty JA, Maloney K, Mayer KH. HIV providers’ perceived barriers and facilitators to implementing pre-exposure prophylaxis in care settings: a qualitative study. AIDS Behav. 2014;18(9):1712–21.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Blackstock OJ, Moore BA, Berkenblit GV, Calabrese SK, Cunningham CO, Fiellin DA, et al. HIV Pre-exposure prophylaxis adoption among primary care physicians: implications for implementation. J Gen Intern Med. 2016. [Epub ahead of print].Google Scholar
  24. 24.
    Lum PJ, Little S, Botsko M, Hersh D, Thawley RE, Egan JE, et al. Opioid-prescribing practices and provider confidence recognizing opioid analgesic abuse in HIV primary care settings. J Acquir Immune Defic Syndr. 2011;56(Suppl 1):S91–7.CrossRefPubMedGoogle Scholar
  25. 25.
    American Academy of HIV Medicine. Practicing HIV specialist (AAHIVS) .2016. Accessed 17 Sept 2016
  26. 26.
    Westergaard RP, Ambrose BK, Mehta SH, Kirk GD. Provider and clinic-level correlates of deferring antiretroviral therapy for people who inject drugs: a survey of North American HIV providers. J Int AIDS Soc. 2012;15(1):10.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Bogart LM, Kelly JA, Catz SL, Sosman JM. Impact of medical and nonmedical factors on physician decision making for HIV/AIDS antiretroviral treatment. J Acquir Immune Defic Syndr. 2000;23(5):396–404.CrossRefPubMedGoogle Scholar
  28. 28.
    Ding L, Landon BE, Wilson IB, Wong MD, Shapiro MF, Cleary PD. Predictors and consequences of negative physician attitudes toward HIV-infected injection drug users. Arch Intern Med. 2005;165(6):618–23.CrossRefPubMedGoogle Scholar
  29. 29.
    Baral SD, Stromdahl S, Beyrer C. The potential uses of preexposure prophylaxis for HIV prevention among people who inject drugs. Curr Opin HIV AIDS. 2012;7(6):563–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Malta M, Magnanini MM, Strathdee SA, Bastos FI. Adherence to antiretroviral therapy among HIV-infected drug users: a meta-analysis. AIDS Behav. 2010;14(4):731–47.CrossRefPubMedGoogle Scholar
  31. 31.
    VanGeest JB, Johnson TP, Welch VL. Methodologies for improving response rates in surveys of physicians: a systematic review. Eval Health Prof. 2007;30(4):303–21.CrossRefPubMedGoogle Scholar
  32. 32.
    Dykema J, Stevenson J, Day B, Sellers SL, Bonham VL. Effects of incentives and pre notification on response rates and costs in a national web survey of physicians. Eval Health Prof. 2011;34(4):434–47.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Klabunde CN, Willis GB, McLeod CC, Dillman DA, Johnson TP, Greene SM, et al. Improving the quality of surveys of physicians and medical groups: a research agenda. Eval Health Prof. 2012;35(4):477–506.CrossRefPubMedGoogle Scholar
  34. 34.
    Krakower DS, Oldenburg CE, Mitty JA, Wilson IB, Kurth AE, Maloney KM, et al. Knowledge, beliefs and practices regarding antiretroviral medications for HIV prevention: results from a survey of healthcare providers in New England. PLoS ONE. 2015;10(7):e0132398.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Mera RM, Palmer S, Mayer B, Magnuson G, RawlingsD, Truvada K (TVD) for HIV pre-exposure prophylaxis (PrEP) utilization in the United States (2013–2015). International AIDS Conference:Durban 2016.Google Scholar
  36. 36.
    Edelman EJ, Dinh AT, Moore BA, Schottenfeld RS, Fiellin DA, Sullivan LE. Human immunodeficiency virus testing practices among buprenorphine-prescribing physicians. J Addict Med. 2012;6(2):159–65.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Underhill K, Morrow KM, Colleran CM, Holcomb R, Operario D, Calabrese SK, et al. Access to healthcare, HIV/STI testing, and preferred pre-exposure prophylaxis providers among men who have sex with men and men who engage in street-based sex work in the US. PLoS ONE. 2014;9(11):e112425.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • E. Jennifer Edelman
    • 1
    • 2
    • 3
    Email author
  • Brent A. Moore
    • 1
    • 2
  • Sarah K. Calabrese
    • 2
    • 3
    • 4
  • Gail Berkenblit
    • 5
  • Chinazo Cunningham
    • 6
  • Viraj Patel
    • 6
  • Karran Phillips
    • 7
  • Jeanette M. Tetrault
    • 1
  • Minesh Shah
    • 8
  • David A. Fiellin
    • 1
    • 2
    • 3
  • Oni Blackstock
    • 6
  1. 1.Yale University School of MedicineNew HavenUSA
  2. 2.Center for Interdisciplinary Research on AIDSYale University School of Public HealthNew HavenUSA
  3. 3.Yale University School of Public HealthNew HavenUSA
  4. 4.George Washington UniversityWashingtonUSA
  5. 5.Johns Hopkins UniversityBaltimoreUSA
  6. 6.Montefiore and Albert Einstein College of MedicineBronxUSA
  7. 7.NIDA-IRP, NIHBaltimoreUSA
  8. 8.University of Illinois – ChicagoChicagoUSA

Personalised recommendations