Table 3:
Physician Reported Barriers to Prescribing PrEP to Adolescents (n=38)
| Barrier | Na (%) |
|---|---|
| Patient-Level Barriers | |
| Lack of acceptability of PrEP to patient | 10 (26) |
| Patient has low perceived risk of HIV | 8 (21) |
| Need to return for monitoring visits | 3 (8) |
| Patient concerns about safety and side effects | 3 (8) |
| Lack of patient, community knowledge about HIV and PrEP | 2 (5) |
| Patient discomfort discussing sexual health with physician | 2 (5) |
| Patients who would adhere to PrEP are those who are likely to consistently use condoms (thus at lower risk of HIV) | 2 (5) |
| Need for patients to see another physician who was more comfortable with PrEP to obtain prescription | 2 (5) |
| Potential inability of adolescents to understand how to use PrEP | 1( 3) |
| Lack of at-risk patients being engaged with the medical system | 1 (3) |
| Stigma associated with seeing an HIV specialist vs. PCP in order to obtain a prescription for PrEP | 1 (3) |
| Potential cultural barriers to PrEP (i.e., populations that would be resistant to PrEP) | 1 (3) |
| Lack of available samples for patients to assess their tolerance to medication before committing to long term use | 1 (3) |
| Physician-Level Barriers | |
| Physician concerns about patient adherence to PrEP | 30 (79) |
| Physician concerns about safety and side effects | 29 (76) |
| Physician concerns about parents being a barrier to PrEP | 19 (50) |
| Lack of physician knowledge about PrEP | 17 (45) |
| Lack of FDA approval for PrEP use in adolescents | 13 (34) |
| Physician concerns about patient adherence to follow-up visits and laboratory monitoring | 10 (26) |
| Physician concerns about confidentiality | 9 (24) |
| Physician concerns related to prescribing to patients <18 | 9 (24) |
| Physician concerns about patients taking PrEP participating in riskier sexual behaviors | 8 (21) |
| Lack of legal clarity about whether PrEP can be prescribed without parental involvement (e.g., confidential care) | 6 (16) |
| Lack of appropriate candidates for PrEP | 6 (16) |
| Potential negative impact of prescribing PrEP on therapeutic relationships with patients and/or their parents | 5 (13) |
| Physician concerns about identifying candidates for PrEP | 5 (13) |
| Lack of official recommendations/guidelines for PrEP use in adolescents | 4 (11) |
| Physician perceived low HIV prevalence in the community limits utility of PrEP | 4 (11) |
| Lack of effectiveness data specific to adolescents | 3 (8) |
| Physician concerns about whether adolescents can understand risks/benefits sufficiently to provide informed consent | 2 (5) |
| Competing priorities at visits may prevent discussion of PrEP | 2 (5) |
| Physician concerns that the published efficacy rates for PrEP were too low to support prescribing to adolescents | 2 (5) |
| PrEP is outside of the physician’s scope of practice | 2(5) |
| Physician concerns about availability of PrEP on the street | 1 (3) |
| Physician concerns about need to deliver social interventions to youth who are high risk enough to warrant PrEP | 1 (3) |
| Physician concerns that PrEP does not provide protection against other STIs (as is afforded by condom use) | 1 (3) |
| Physician perception that PrEP is a subspecialty service | 1 (3) |
| Discussions about sexual health do not consistently occur | 1 (3) |
| Need for follow up visits is a barrier for physician | 1 (3) |
| Physician concerns about reimbursement for PrEP services | 1 (3) |
| Physician concerns about potential medicolegal risks to physician and practice associated with providing PrEP | 1 (3) |
| Physician concerns that prescribing PrEP may be construed as condoning high risk behavior | 1 (3) |
| Physician preference for other behavioral interventions (i.e., abstinence, limiting partners, condom use) | 1 (3) |
| Physician concerns about HIV viral resistance | 1 (3) |
| Physician concerns about contradictory messages in encouraging long-acting contraception but a daily pill for HIV prevention | 1 (3) |
| Physician concerns that patient may need prolonged use of PrEP due to ongoing risk behaviors | 1 (3) |
| Physician concerns about whether a pelvic exam would need to be done prior to prescribing PrEP | 1 (3) |
| Physician concerns about how to ensure patient is HIV-uninfected before starting PrEP | 1 (3) |
| Physician concerns about poor use of healthcare dollars if patient fills prescription but is not adherent to medication | 1 (3) |
| Systems-Level Barriers | |
| Cost and lack of coverage by insurance for PrEP | 33 (87) |
| Logistical and clinic systems barriers | 15 (39) |
| Lack of access to medication or PrEP prescribers | 8 (21) |
| Lack of community awareness, marketing about PrEP and HIV | 4 (11) |
| Systems financial barriers (i.e., cost of staff resources) | 2 (5) |
| Lack of identified provider for PrEP to minors | 2 (5) |
| Need to access PrEP outside of PCP practice | 1 (3) |
PrEP: pre-exposure prophylaxis; HIV: human immunodeficiency virus; FDA: U.S. Food and Drug administration; PCP: primary care physician
a.
Number of participants who reported each barrier.