Knowledge, Beliefs and Practices Regarding Antiretroviral Medications for HIV Prevention: Results from a Survey of Healthcare Providers in New England

Background
Antiretroviral treatment for HIV-infection before immunologic decline (early ART) and pre-exposure chemoprophylaxis (PrEP) can prevent HIV transmission, but routine adoption of these practices by clinicians has been limited.
Methods
Between September and December 2013, healthcare practitioners affiliated with a regional AIDS Education and Training Center in New England were invited to complete online surveys assessing knowledge, beliefs and practices regarding early ART and PrEP. Multivariable models were utilized to determine characteristics associated with prescribing intentions and practices.
Results
Surveys were completed by 184 practitioners. Respondent median age was 44 years, 58% were female, and 82% were white. Among ART-prescribing clinicians (61% of the entire sample), 64% were aware that HIV treatment guidelines from the Department of Health and Human Services recommended early ART, and 69% indicated they would prescribe ART to all HIV-infected patients irrespective of immunologic status. However, 77% of ART-prescribing clinicians would defer ART for patients not ready to initiate treatment. Three-fourths of all respondents were aware of guidance from the U.S. Centers for Disease Control and Prevention recommending PrEP provision, 19% had prescribed PrEP, and 58% of clinicians who had not prescribed PrEP anticipated future prescribing. Practitioners expressed theoretical concerns and perceived practical barriers to prescribing early ART and PrEP. Clinicians with higher percentages of HIV-infected patients (aOR 1.16 per 10% increase in proportion of patients with HIV-infection, 95% CI 1.01–1.34) and infectious diseases specialists (versus primary care physicians; aOR 3.32, 95% CI 0.98–11.2) were more likely to report intentions to prescribe early ART. Higher percentage of HIV-infected patients was also associated with having prescribed PrEP (aOR 1.19, 95% CI 1.06–1.34), whereas female gender (aOR 0.26, 95% CI 0.10–0.71) was associated with having not prescribed PrEP.
Conclusions
These findings suggest many clinicians have shifted towards routinely recommending early ART, but not PrEP, so interventions to facilitate PrEP provision are needed.

背景
针对HIV感染的早期抗反转录病毒治疗（early ART，免疫功能下降前启动）与暴露前化学预防（pre-exposure chemoprophylaxis，PrEP）均可阻断HIV传播，但临床医师对上述干预手段的常规应用仍存在局限。

方法
2013年9月至12月期间，研究邀请隶属于新英格兰地区艾滋病教育与培训中心的医护人员完成线上问卷，以评估其针对早期抗反转录病毒治疗与暴露前化学预防的认知、态度与临床实践情况。本研究采用多变量模型，分析与处方意向及临床实践相关的特征因素。

结果
共有184名医护人员完成了问卷调研。受访者的中位年龄为44岁，其中58%为女性，82%为白人。在开具抗反转录病毒治疗处方的医师（占总样本的61%）中，64%知晓美国卫生与公众服务部（Department of Health and Human Services, HHS）发布的HIV治疗指南推荐早期抗反转录病毒治疗，69%表示会为所有HIV感染者开具抗反转录病毒治疗处方，无论其免疫功能状态如何。但77%的处方医师会为尚未准备好启动治疗的患者暂缓抗反转录病毒治疗。全部受访者中有四分之三知晓美国疾病控制与预防中心（U.S. Centers for Disease Control and Prevention, CDC）发布的关于提供暴露前化学预防的指南，19%的医师曾开具过暴露前化学预防处方，而在未开具过该处方的医师中，58%计划未来开展此类处方行为。医护人员均表达了针对早期抗反转录病毒治疗与暴露前化学预防的理论顾虑与实际应用障碍。
分析显示，接诊HIV感染者比例更高的医师（每增加10%的HIV感染者占比，调整后比值比（adjusted Odds Ratio, aOR）=1.16，95%置信区间（confidence interval, CI）：1.01~1.34）与感染科专科医师（相较于全科医师，aOR=3.32，95% CI：0.98~11.2）更倾向于报告有早期抗反转录病毒治疗的处方意向。接诊HIV感染者比例更高也与曾开具暴露前化学预防处方相关（aOR=1.19，95% CI：1.06~1.34），而女性性别则与未开具过暴露前化学预防处方相关（aOR=0.26，95% CI：0.10~0.71）。

结论
本研究结果显示，多数临床医师已转向常规推荐早期抗反转录病毒治疗，但尚未普及暴露前化学预防的应用，因此亟需开发可促进暴露前化学预防处方开展的干预措施。