Abstract
In 2020, over 1.2 million people were at risk of acquiring human immunodeficiency virus (HIV), though only 25% were prescribed pre-exposure prophylaxis (PrEP). Given the multitude of dermatologic manifestations of HIV and other sexually transmitted infections, dermatologic care can serve as the entry point to the HIV care continuum. Currently, there is limited data on specialists’ perspectives on HIV PrEP prescribing. We aimed to survey clinicians and trainees in an academic dermatology department about HIV PrEP-related knowledge, attitudes, and practices. Survey questions were adapted from existing literature on HIV stigma and PrEP-related knowledge, attitudes, and practices. Composite scores for each domain were averaged and compared between clinicians and trainees using Wilcoxon’s signed rank test or Fisher’s exact test. Of 135 providers invited, 31 (23%) completed the survey (11 clinicians and 20 trainees). Of the 31 participants, 16 (52%) had specialized HIV experience and training. When asked about discriminatory beliefs, 9 participants (29%) agreed that HIV infection is a “consequence of irresponsible behavior.” PrEP knowledge was low, with 13 (42%) participants answering zero out of 3 PrEP knowledge questions correctly. Additionally, 10 (91%) clinicians reported poor knowledge of PrEP side effects, and 8 clinicians (73%) indicated they were “not comfortable at all” in prescribing PrEP. No participant had prescribed PrEP, and 22 (70%) participants had never discussed PrEP with patients. Dermatology clinicians and trainees reported some levels of HIV stigma. Substantial gaps in PrEP knowledge and discussion were reported despite prior HIV discrimination training and HIV-related practice experience. Study limitations include a small sample size and a modest response rate. Addressing stigma among dermatologists and improving HIV PrEP education is vital to enhancing the healthcare outcomes of people living with HIV.
Keywords: Pre-exposure Prophylaxis, PrEP, HIV infection, Social stigma, Dermatology, Surveys and Questionnaires, Health Knowledge, Attitudes, Practice
Research Letter
In 2020, over 1.2 million people were at risk of acquiring human immunodeficiency virus (HIV), though only 25% were prescribed pre-exposure prophylaxis (PrEP) [4]. Given the multitude of dermatologic manifestations of HIV and other sexually transmitted infections, particularly among sexual and gender minorities, dermatologic care can facilitate patient entry into the HIV care and PrEP continuum [5]. Currently, there is limited data on specialists’ perspectives on HIV PrEP prescribing. We aimed to survey clinicians and trainees in an academic dermatology department about HIV PrEP-related knowledge, attitudes, and practices.
An anonymous survey approved by the Emory University institutional review board was emailed to clinicians (attending physicians and advanced practice providers) and trainees (resident physicians and medical students) at the Emory University Department of Dermatology. Questions were adapted from literature on HIV stigma and PrEP-related knowledge, attitudes, and practices [1–3]. Composite scores were compared between clinicians and trainees using Fisher’s Exact Test or Wilcoxon’s signed-rank test.
Among 135 dermatology providers invited, 31 (23%) completed the survey including 11 clinicians and 20 trainees. Of the 31 participants, 16 (52%) had specialized HIV experience and received training in HIV stigma and discrimination (Table 1). No participants in our survey had ever prescribed PrEP and 68% of participants had never discussed PrEP with a patient. There was no significant difference in PrEP self-rated knowledge between clinicians and trainees (P=0.11). Most clinicians (91%) and trainees (80%) reported poor or fair knowledge of PrEP side effects. Tested PrEP knowledge was also low with 42% of participants answering all PrEP knowledge questions incorrectly. A larger proportion of clinicians (73%) compared to trainees (15%) reported feeling not comfortable at all prescribing PrEP to patients. When asked about differences in providing care between HIV positive and HIV negative patients, few trainees agreed that they would be less likely to biopsy (5%), suture during biopsies (15%), or refer to another surgical specialty (10%) for people living with HIV (PLWH), while no clinicians agreed to these statements. When asked about discriminatory beliefs, 9 participants (29%) agreed that HIV infection is a consequence of irresponsible behavior and 3 participants (10%) agreed that most PLWH have had many sexual partners (Table 2).
Table 1.
Participant demographics & practice characteristics
| Characteristic | n (%) |
|---|---|
| Total Invitees | 135 |
| Total Participants | 31 |
| Age, years (Median, IQR) | 30 (10) |
| Healthcare Experience, years (Median, IQR) | 7 (12) |
| Gender | |
| Male | 13 (42) |
| Female | 18 (58) |
| Occupation | |
| Dermatology Attending | 10 (32) |
| Dermatology Resident | 8 (26) |
| Physician's Assistant | 1 (3) |
| Medical Student | 11 (35) |
| Other | 1 (3.2) |
| Specialized HIV Experience | |
| Yes | 16 (52) |
| No | 15 (48) |
| Specialized Trainings Received | |
| HIV Stigma and Discrimination | 16 (52) |
| Infection Control and Universal Precautions | 30 (97) |
| Patients' Informed Consent, Privacy, and Confidentiality | 30 (97) |
| Key Population Stigma and Discrimination | 19 (61) |
IQR interquartile range, HIV human immunodeficiency virus
Table 2.
HIV stigma, PrEP knowledge & attitudes compared between clinicians and trainees
| Clinicians (n=11) | Trainees (n=20) | |
|---|---|---|
| Survey Questions | n (%) | n (%) |
| Attitudes towards people living with HIV | ||
| Most people living with HIV have had many sexual partners.a | ||
| Agree | 1 (9.1) | 2 (10) |
| Disagree | 4 (36) | 13 (65) |
| Strongly Disagree | 6 (55) | 5 (25) |
| People get infected with HIV because they engage in irresponsible behavior.a | ||
| Agree | 3 (27) | 6 (30) |
| Disagree | 3 (27) | 7 (35) |
| Strongly Disagree | 5 (45) | 7 (35) |
| Self-rated Knowledge of PrEP | ||
| Excellent | 0 (0) | 4 (20) |
| Very Good | 1 (9) | 2 (10) |
| Good | 3 (27) | 7 (35) |
| Fair | 4 (36) | 7 (35) |
| Poor | 3 (27) | 0 (0) |
| Self-rated Knowledge of PrEP Side Effects | ||
| Excellent | 0 (0) | 1 (5) |
| Very Good | 1 (9) | 2 (10) |
| Good | 0 (0) | 1 (5) |
| Fair | 4 (36) | 7 (35) |
| Poor | 6 (55) | 9 (45) |
| PrEP Knowledge Score b | ||
| 0 | 6 (55) | 7 (35) |
| 1 | 3 (27) | 9 (45) |
| 2 | 2 (18) | 4 (20) |
| 3 | 0 (0) | 0 (0) |
| Level of Comfort Prescribing PrEP | ||
| Not Comfortable at All | 8 (73) | 3 (15) |
| Somewhat Comfortable | 1 (9) | 5 (25) |
| Neither Comfortable nor Uncomfortable | 0 (0) | 1 (5) |
| Comfortable | 2 (18) | 0 (0) |
| Extremely Comfortable | 0 (0) | 1 (5) |
| Not Applicable/Missing | 0 (0) | 10 (50) |
| Dermatology-Related Stigma c | ||
| I am less likely to biopsy if I am seeing a patient who is HIV positive as compared to a patient who is HIV negativea | ||
| Agree | 0 (0) | 2 (10) |
| Neither Agree nor Disagree | 2 (18) | 4 (20) |
| Disagree | 4 (36) | 4 (20) |
| Strongly Disagree | 5 (45) | 4 (20) |
| Missing | 0 (0) | 1 (5) |
| I am less likely to suture during biopsies in a patient who is HIV positive as compared to HIV negativea | ||
| Agree | 0 (0) | 3 (15) |
| Neither Agree nor Disagree | 2 (18) | 4 (20) |
| Disagree | 4 (36) | 5 (25) |
| Strongly Disagree | 5 (45) | 7 (35) |
| Missing | 0 (0) | 1 (5) |
| I am more likely to refer an HIV positive patient to another specialty for surgical excision as compared to an HIV negative patienta | ||
| Agree | 0 (0) | 2 (10) |
| Neither Agree nor Disagree | 1 (9) | 7 (35) |
| Disagree | 3 (27) | 4 (20) |
| Strongly Disagree | 7 (64) | 6 (30) |
| Missing | 0 (0) | 1 (5) |
HIV human immunodeficiency virus, PrEP pre-exposure prophylaxis
No survey participant chose “strongly agree” thus this survey option was excluded from the table
Knowledge on PrEP medications, efficacy, and side effects were assessed using 3 questions, with the sum of correct answers creating a knowledge score ranging from 0–3
Dermatology-related stigma was measured on a five-point Likert scale from strongly agree to strongly disagree
Our survey provided perspectives from dermatology clinicians and trainees showing varying amounts of HIV stigma and substantial gaps in PrEP knowledge, despite prior HIV-related training and practice experience. Despite some participants reporting stigmatizing beliefs, most participants expressed that the types of dermatological procedures and care provided would not differ between PLWH and HIV-negative patients. Lack of provider knowledge and comfort with prescribing PrEP hinders the implementation of the Ending the HIV Epidemic in the U.S. Initiative despite PrEP being safe and effective in reducing HIV transmission [2, 4]. This pilot survey was limited by a modest sample size and response rate; results should be confirmed in future large-scale studies. Dermatologists should acknowledge HIV-related provider stigma and facilitate patient entry into the HIV care and PrEP continuum. Interventions to reduce HIV stigma and improve PrEP education are vital to enhancing the healthcare outcomes of PLWH.
Footnotes
Statements and Declarations: Dr Yeung is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases under award numbers L30AR076081 and K23AR075888. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or US Department of Veterans Affairs. The authors report no other conflicts of interest in this work.
References
- 1.Blackstock OJ, Moore BA, Berkenblit GV, et al. A Cross-Sectional Online Survey of HIV Pre-Exposure Prophylaxis Adoption Among Primary Care Physicians. J Gen Intern Med. 2017;32(1):62–70. 10.1007/s11606-016-3903-z (in eng). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Blumenthal J, Jain S, Krakower D, et al. Knowledge is Power! Increased Provider Knowledge Scores Regarding Pre-exposure Prophylaxis (PrEP) are Associated with Higher Rates of PrEP Prescription and Future Intent to Prescribe PrEP. AIDS Behav. 2015;19(5):802–10. 10.1007/s10461-015-0996-z (in eng). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Castel AD, Feaster DJ, Tang W, et al. Understanding HIV Care Provider Attitudes Regarding Intentions to Prescribe PrEP. J Acquir Immune Defic Syndr. 2015;70(5):520–8. 10.1097/qai.0000000000000780 (in eng). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Centers for Disease Control and Prevention. Core indicators for monitoring the Ending the HIV Epidemic initiative (preliminary data): National HIV Surveillance System data reported through March 2021; and preexposure prophylaxis (PrEP) data reported through December 2020. HIV Surveillance Data Tables 2021;2(No. 3). http://www.cdc.gov/hiv/library/reports/hivsurveillance.html. Published July 2021. Accessed November 2022. [Google Scholar]
- 5.Yeung H, Luk KM, Chen SC, et al. Dermatologic care for lesbian, gay, bisexual, and transgender persons: Epidemiology, screening, and disease prevention. J Am Acad Dermatol. 2019;80(3):591–602. 10.1016/j.jaad.2018.02.045 (in eng). [DOI] [PMC free article] [PubMed] [Google Scholar]