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. Author manuscript; available in PMC: 2020 Nov 10.
Published in final edited form as: J Assoc Nurses AIDS Care. 2017 Nov 22;29(1):83–92. doi: 10.1016/j.jana.2017.11.002

Do You PrEP? A Review of Primary Care Provider Knowledge of PrEP and Attitudes on Prescribing PrEP

Leah Turner 1,*, Abbey Roepke 1, Emily Wardell 1, Anne M Teitelman 1
PMCID: PMC7653672  NIHMSID: NIHMS1643216  PMID: 29274655

Abstract

Oral preexposure prophylaxis (PrEP) has been proven to be a safe and effective means of preventing HIV. The purpose of our literature review was to examine primary care provider knowledge and attitudes about prescribing PrEP. PubMed, CINAHL, Web of Science, and Scopus were searched and additional articles were identified through other sources, yielding 11 articles that met inclusion criteria. Overall, there was high variability among providers regarding attitudes, knowledge, and prescriptive practices related to PrEP. PrEP continues to be an underutilized HIV prevention intervention and more research focusing on provider-specific factors is warranted.

Keywords: attitudes and beliefs, health knowledge, HIV, preexposure prophylaxis, primary care

As of 2013, there were approximately 1.2 million HIV-infected individuals and an estimated 160,000 undiagnosed individuals living in the United States (Centers for Disease Control and Prevention [CDC], 2016b). In 2015 alone, 39,513 new cases of HIV were diagnosed in the United States (CDC, 2016b). Populations most affected by HIV in 2015 included men who have sex with men; heterosexual intravenous drug users; and African American, Hispanic, and Latino populations (CDC, 2016b). Although the rate of HIV diagnoses decreased 19% from 2005 to 2014, HIV continues to burden these populations despite current HIV testing and prevention efforts (CDC, 2016a). There is, therefore, a need for additional HIV prevention methods.

In 2012, the U.S. Food and Drug Administration (FDA) approved the use of emitricibine/tenofovir disproxil fumarate (Truvada®; Gilead Sciences Inc., Foster City, CA) as the first once-daily drug indicated for antiretroviral preexposure prophylaxis (PrEP) (CDC, 2014). In 2014, the CDC released clinical practice guidelines for health care providers, with updates in 2015 and 2017, to aid in prescribing PrEP (CDC, 2014). The approval of PrEP by the FDA and the release of CDC guidelines occurred after the findings of several large clinical studies supported safety and efficacy among populations at risk for HIV infections. In fact, several large clinical studies have shown that the daily use of PrEP is 93% effective in preventing HIV transmission in high-risk populations (CDC, 2014). Not only have these studies provided evidence concerning the efficacy of PrEP, but several studies have also provided support for the safety of PrEP in these at-risk populations. Studies have found no statistically significant difference in adverse events associated with PrEP compared to placebo (Baeten et al., 2012; Choopanya et al., 2013; Grant et al., 2010; Grohskopf et al., 2013; Thigpen et al., 2012). A systematic review and meta-analysis found that the adverse events for PrEP versus placebo were similar when controlling for potential confounding variables such as adherence, drug regimen, sex, dosing, and age (Fonner et al., 2016). In addition, risk compensation has been addressed in various studies. Risk compensation is the belief that as disease-prevention strategies such as PrEP become available, people are more likely to engage in risk behaviors such as condomless sex (Grant et al., 2014). Most studies have found either no change or slight increases in condom use during receptive and insertive anal intercourse among PrEP users at follow-up and over time (CDC, 2014; Fonner et al., 2016; Grant et al., 2014; Liu et al., 2013; Marcus et al., 2013; Mugwanya et al., 2013). These large landmark studies, along with the approval of the FDA and CDC guidelines, support the use of PrEP in populations at risk.

Studies to describe factors associated with PrEP use have largely focused on patient-level factors, with only a small number of studies examining providers (Sowicz, Teitelman, Coleman, & Brawner, 2014). Provider-level factors that could influence the use and prescription of PrEP range from background factors such as age, years of clinical experience, and knowledge of PrEP, to behavioral factors such as attitudes surrounding the use of PrEP. A systematic review of studies that used health behavior theories to explain a variety of provider behaviors, including prescribing practices, found 78 studies that measured determinants of intentions, behaviors, or both. The most frequently used theories were the Theory of Reasoned Action, or its extension, the Theory of Planned Behavior (Godin, Belanger-Gravel, Eccles, & Grimshaw, 2008). The Theory of Planned Behavior has been shown to explain variance in provider behavior (Godin et al., 2008) supporting the use of social-cognitive theories to predict health care provider intentions and behaviors, including prescriptive practices.

The Integrative Behavioral Model (IBM) expands on the Theory of Planned Behavior/Theory of Reasoned Action models by including additional factors and variables that affect intention and behavior (Fishbein & Azjen, 2010). According to the IBM, intention to perform a particular behavior is the best predictor of behavior. In turn, attitudes, norms, and perceived control in relation to the behavior predict intention. Attitude is a general view about the outcome of a behavior (beneficial or harmful), norms are a perception of others’ views of behaviors (approval or disapproval), and perceived control is whether the individual thinks it is easy or hard to perform the behavior. Underlying attitudes are specific behavioral beliefs about the behavior (e.g., prescribing PrEP to patients will lower the risk for acquiring HIV). Norms are influenced by normative beliefs (e.g., if one thinks his/her professional colleagues support the idea of prescribing PrEP). Perceived control is related to control beliefs (e.g., if a provider thinks insurance coverage will be a barrier). The IBM can be used to identify modifiable beliefs that can be targeted in interventions for behavior change (Fishbein & Azjen, 2010). Given the limited body of existing literature focused on provider-level factors regarding PrEP, the constructs of the IBM can be used to describe relationships between provider knowledge, beliefs, attitudes, norms, perceived control, and intentions and behaviors in relation to the prescription of PrEP (see Figure 1).

Figure 1.

Figure 1.

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The Integrative Behavioral Model as it applies to PrEP Prescribing Behavior was used as a framework in this state of the science review to examine primary care provider factors toward prescribing PrEP. This figure highlights the factors present in the current review and their potential relationship to influence behavior. PrEP = preexposure prophylaxis.

The purpose of our review was to critically appraise and synthesize the current literature on provider-level factors that impact appropriate prescription of PrEP in the primary care setting. We specifically focused on knowledge and attitudes, as these are major constructs in the IBM. We defined knowledge as information, awareness, and/or skills acquired by a person through experience or education. We defined attitudes as relating to whether providers perceived PrEP as beneficial or harmful. Therefore, our initial research questions were (a) what were provider knowledge and attitudes about the prescription of PrEP? and (b) what was the quality of evidence in the current body of research?

Methods

A literature search was performed in November 2016 and again in January 2017 using four electronic bibliographic databases: PubMed, CINAHL, Web of Science, and Scopus. In PubMed, the medical subject heading (MeSH) term pre-exposure prophylaxis and the key words primary care providers and knowledge and attitudes were used. The CINAHL database was searched using the keywords primary care providers, pre-exposure prophylaxis, and knowledge and attitudes. The Web of Science database was searched using the topics primary care providers, pre-exposure prophylaxis, and knowledge and attitudes. The Scopus database was searched using the title-abstract-keywords primary care providers, pre-exposure prophylaxis, and knowledge and attitudes. Given the recent nature of the topic of interest, English language and original databased studies conducted in the United States and Canada were the only limitations applied to the searches. Additional articles were identified through article reference lists and secondary sources and included if they related to the topic of interest. Duplicate articles were deleted. Abstracts and titles of remaining articles were screened for relevance. Remaining full text articles were then read for inclusion or exclusion in this review (see Figure 2).

Figure 2.

Figure 2.

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Prisma flow diagram detailing the search and selection process of articles pertaining to knowledge of PrEP and attitudes on prescribing PrEP in the primary care setting. PrEP = preexposure prophylaxis.

The Grade of Recommendations Assessment Development and Evaluation (GRADE) approach was used to rate the quality of evidence of each study included in the table of evidence (Guyatt et al., 2011; see Table 1). Each article was analyzed by three graduate nursing students trained in the GRADE approach as part of the research curriculum at the University of Pennsylvania School of Nursing. GRADE criteria (quality, risk of bias, consistency, directness, and precision) were used to rate the quality of evidence as very low, low, moderate, or high (Guyatt et al., 2011). Faculty with experience in nursing research oversaw the analysis. After all studies were reviewed, discrepancies among reviewers were resolved by consensus.

Table 1.

Quality of Evidence Table for Studies Addressing Knowledge of and Attitudes on Prescribing Preexposure Prophylaxis in Primary Care Settings

Author Publication Year Type of Study Method Study Sample and Setting Quality of Evidence (GRADEa)
Bacon et al 2017 Descriptive Quantitative N = 99 primary care providers and HIV specialist providers at San Francisco General Hospital and UCSF Setting: Online Low
Blackstock et al 2016 Descriptive Quantitative N = 246 attending physicians, fellows, or residents involved in direct outpatient care who were members of the Society of General Internal Medicine Setting = Online Low
Hakre et al 2016 Descriptive Quantitative N = 403 U.S. Air force active duty primary care providers (physicians, physician assistants, nurse practitioners) and infectious disease physicians
Setting = Online		 Low
Karris et al 2014 Descriptive Quantitative N = 573 adult infectious disease physicians in the U.S. and Canada who are members of the IDSA Emerging Infectious Disease Network
Setting = Online		 Low
Krakower et al 2015 Descriptive Quantitative N = 184 health practitioners associated with the New England AIDS Education Training Center
Setting = Online		 Low
Krakower et al 2014 Descriptive Qualitative N = 39 Boston-area HIV providers Setting = Boston HIV clinics Low
Petroll et al 2016 Descriptive Quantitative N = 525 health care providers from 10 U.S. cities.
Setting = Online		 Low
Seidman et al 2016 Descriptive Quantitative N = 495 family planning providers throughout the U.S.
Setting = Online		 Low
Smith et al 2016 Descriptive Quantitative N = 9,023 physicians and NPs in the U.S. surveyed between 2009–2015
Setting = Online		 Moderate
Tripathi et al 2012 Descriptive Quantitative N = 360 health care providers at sexually transmitted disease and family planning care centers in South Carolina and Mississippi between 2006 and 2008
Setting = Clinic		 Low
White et al 2012 Descriptive Quantitative Massachusetts physicians surveyed before (n = 178) and after (n = 115) preexposure prophylaxis initiative data release
Setting = Online		 Low
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Note. GRADE = Grade of Recommendations Assessment Development and Evaluation; UCSF = University of California San Francisco; N = number; U.S. = United States; IDSA = Infectious Disease Society of America; NPs = nurse practitioners.

a.

GRADE is a tool used to rate the quality of evidence. GRADE provides criteria for rating the quality of evidence as very low, low, moderate, or high.

Results

A total of 11 articles were included in our review. Study sizes ranged from 39 participants to more than 9,000 participants. A majority were online surveys, with the exception of one focus group, and were conducted between 2006 and 2015. Five studies were conducted before the 2014 CDC PrEP guidelines were published (Karris, Beekmann, Mehta, Anderson, & Polgreen, 2014; Krakower, Ware, Mitty, Maloney, & Mayer, 2014; Krakower et al., 2015; Tripathi, Ogbuanu, Monger, Gibson, & Duffus, 2012; White, Mimiaga, Krakower, & Mayer, 2012). Four studies were conducted after the 2014 CDC PrEP guidelines were published (Bacon et al., 2017; Blackstock et al., 2016; Petroll et al., 2016; Seidman, Carlson, Weber, Witt, & Kelly, 2016). One study was conducted after the 2015 CDC guideline update was published (Hakre et al., 2016). In addition, one study measured provider knowledge and attitudes before and after the 2014 CDC guidelines were published (Smith, Mendoza, Stryker, & Rose, 2016). In the 11 studies included in our review, participants were largely physicians, with both primary care and infectious disease specialists represented. Seven studies included advanced practice providers, such as nurse practitioners and physician assistants (PA; Bacon et al., 2017; Hakre et al., 2016; Krakower et al., 2015; Petroll et al, 2016; Seidman et al., 2016; Smith et al., 2016; Tripathi et al., 2012). One study included registered nurses (Seidman et al., 2016). Six studies included providers who specialized in HIV care (Bacon et al., 2017; Hakre et al., 2016; Krakower et al., 2014; Krakower et al., 2015; Petroll et al., 2016; White et al., 2012). The surveys and focus groups addressed topics such as experience caring for patients living with HIV infection; knowledge of, awareness of, and willingness to prescribe PrEP; experience prescribing PrEP or antiretroviral therapy; knowledge of CDC guidelines; and attitudes about the use of and intention to prescribe PrEP. Although beliefs were not an initial focus, they are presented in the results as they were commonly measured in the articles and were theoretically related to attitudes in the IBM.

Provider Knowledge

In general, HIV care providers were more knowledgeable about and willing to prescribe PrEP than primary care providers (Blackstock et al., 2016; Hakre et al., 2016; Krakower et al., 2015; Petroll et al., 2016; Seidman et al., 2016; Smith et al., 2016; Tripathi et al., 2012; White et al., 2012). Bacon and colleagues (2017) found that for HIV specialists and nonspecialists in the San Francisco Bay Area, 92% of providers were aware of PrEP but only 26% had provided PrEP. A 2015 survey of Air Force primary care providers and infectious disease physicians asked participants to rate their knowledge of efficacy of PrEP in clinical trials and components of CDC guideline recommendations (e.g., risk assessment, clinical eligibility, testing for acute HIV infection, screening for hepatitis B, and other sexually transmitted diseases). Sixty-two percent of Air Force primary care providers rated their knowledge of PrEP as poor, compared to 5% of infectious disease specialists (Hakre et al., 2016); areas of knowledge deficit were not specified. One study delineated the difference in awareness of PrEP and prescribing intentions between physicians and advanced practice nurses (APNs)/PAs (Krakower et al., 2015). They found that, while APNs/PAs were more likely than primary care providers to have prescribed PrEP, it was difficult to draw conclusions due to the small sample size (N = 184) and wide confidence intervals of the study. Petroll and colleagues (2016) found that 64% of HIV care providers (n = 237) prescribed PrEP, compared to 17% of primary care providers (n = 278). Overall, providers with prior experience caring for patients with HIV and experience prescribing antiretroviral therapy were more willing to prescribe PrEP.

Although our search did not aim to examine the influence of CDC guidelines, several studies concluded that knowledge related to the guidelines potentially affected PrEP prescription practices (Hakre et al., 2016; Krakower et al., 2014; Krakower et al., 2015; Smith et al., 2016; White et al., 2012). A qualitative study conducted in 2012, after the CDC had issued provisional guidance on the use of PrEP in men who have sex with men, found that providers viewed prescribing guidelines as favorable, and felt they would enhance comfort and willingness to prescribe PrEP (Krakower et al., 2014). Furthermore, providers stated that guidelines would inform the safe execution and implementation of a medical intervention for which many providers had little prior experience (Krakower et al., 2014). Krakower and colleagues (2015) surveyed health care practitioners associated with an AIDS Education and Training Center in New England about PrEP knowledge, as assessed by awareness of FDA approval and CDC guidelines. They found that 89% of participants were aware of PrEP, 79% knew PrEP was approved by the FDA, and about 75% knew about the CDC guidelines for PrEP (Krakower et al., 2015). Despite this survey being conducted more than 2 years after the first set of CDC guidelines on PrEP was issued, one-fourth of providers specializing in HIV-related care remained unaware of the published guidelines (Krakower et al., 2015). Additionally, Seidman and colleagues (2016) surveyed 495 U.S. family planning providers and found that approximately 33% had exposure to any PrEP guidelines. Overall, prescribing guidelines from normative bodies such as the CDC were described as an important factor to consider in relation to provider willingness to prescribe PrEP.

Provider Attitudes

Provider attitudes were explored through structured questionnaires, with the exception of one qualitative study. Although not a search term, behavioral and control beliefs appeared in conjunction with attitudes in the reviewed literature.

Of 99 San Francisco-based providers surveyed about attitudes and training related to PrEP, 65% desired further training in areas such as HIV testing frequency, contraindications to PrEP use, laboratory monitoring, PrEP eligibility, and adherence counseling (Bacon et al., 2017). Desire for further training was associated with concerns related to side effects and drug resistance; however, the researchers found no association between concerns about PrEP and willingness to prescribe (Bacon et al., 2017). Logistical concerns about prescribing included clinical and laboratory monitoring of patients using PrEP and time constraints limiting patient education and counseling. Cost of antiretroviral medications and uncertainty about insurance coverage, as well as the high cost of continued medical monitoring of patients, were other barriers to prescribing PrEP (Krakower et al., 2014).

Potential lack of medication adherence and increased risk behaviors were perceived potential harms cited by primary care providers. Participants in Boston-area focus groups expressed apprehension that patients would use PrEP intermittently rather than daily as prescribed (Krakower et al., 2014). In addition, the perception that PrEP use would increase risk behaviors, and specifically, the rates of condomless sex, was prevalent in the studies included in this review. Petroll and colleagues (2016) found that approximately one-fifth of the primary care providers and HIV specialists surveyed shared the idea that risk behaviors would increase with PrEP prescription. Blackstock and colleagues (2016) found that, compared to nonadopters of PrEP, the providers who had adopted PrEP, as defined by ever prescribing or referring a patient for PrEP, were less likely to perceive it as being moderately likely to increase risk behaviors. Additionally, adopters of PrEP were more likely than nonadopters of PrEP to perceive PrEP as being extremely safe. They concluded that concerns about the safety of PrEP and increases in risk behaviors potentially interfered with prescribing (Blackstock et al., 2016).

Medication side effects were another potential harm noted by both primary care providers and infectious disease specialists. Two studies found that providers were concerned about putting uninfected individuals at risk for negative side effects (Hakre et al., 2016; Krakower et al., 2014). Another commonly cited concern was the belief that PrEP would contribute to the emergence of drug resistance (Karris et al., 2014).

Quality of Evidence

The studies included in our review had an overall low quality of evidence rating, with one study rated as moderate (Smith et al., 2016). This was due to the observational, cross-sectional nature of the study designs. Additionally, studies used convenience sampling and self-reported data from online surveys. Also, while some studies did use comparison groups, most of the findings were descriptive and did not test hypotheses. Therefore, comparisons or correlations were limited. Furthermore, no studies tested interventions designed to enhance provider knowledge and attitudes to promote wider adoption of PrEP.

Discussion

The literature included in our review focused on provider-level factors, with an emphasis on describing knowledge and attitudes that could impact the appropriate prescription of PrEP. While both the FDA and CDC have issued guidelines to promote the safe and effective use of PrEP for HIV prevention, no studies have been conducted to test the effects of these guidelines on provider prescribing intentions and practices. This could be an important area for future research.

Despite CDC guidelines being released in 2014 and updated in 2015 and 2017, providers continued to express desires for increased knowledge and training on PrEP. Given the narrow time interval, the four studies published shortly after the release of the 2014 CDC guidelines may not accurately reflect current practices in adoption and prescribing patterns (Bacon et al., 2017; Blackstock et al., 2016; Petroll et al., 2016; Seidman et al., 2016). Additional research is needed in order to determine if the updated CDC guidelines have impacted the awareness, knowledge, and actual prescription of PrEP.

The reviewed studies found that infectious disease specialists experienced in treating patients living with HIV were more willing to prescribe PrEP than primary care providers; however, the associations among beliefs, attitudes, and intentions to prescribe were infrequently measured. One notable exception was the study by Bacon and colleagues (2017) that found no association between concerns for safety or drug resistance and willingness to prescribe PrEP, although these concerns were associated with lack of knowledge. This suggested that increased knowledge about PrEP may be a crucial factor to increasing PrEP uptake.

Social-cognitive factors related to prescribing and intention or willingness to prescribe was another important area that could be further expanded in future research. Only one study identified predictors of PrEP adoption among primary care providers, and they found that adoption of PrEP was associated with more favorable views about safety and risk compensation (Blackstock et al., 2016). Additional research on predictors of actual prescribing behavior is needed to advance the science surrounding this topic and further increase the adoption of PrEP in primary care and other settings. We suggest that a theoretical model of behavior, such as the Integrated Behavioral Model, be used in future studies to guide consistency in this body of emerging literature.

Our synthesis of common attitudes and beliefs among providers related to PrEP prescription offers insight to those seeking to develop future training programs. Education about PrEP should address misconceptions related to medication adherence, resistance, logistics, side effects, and the potential to induce risky behavior (Hakre et al., 2016; Karris et al., 2014; Krakower et al., 2014). Of note, the majority of the reviewed studies did not include an assessment of preferred method of training desired by providers. While Bacon and colleagues (2017) found that providers expressed interest in a variety of training methods, including self-directed, online learning and face-to-face training, more data on learning preferences would be valuable to inform the design of future training programs.

There is still a need among primary care providers for increased knowledge about PrEP, and in particular, the CDC clinical guidelines. Given FDA approval of the first generic emitricitabine/tenofovir in June 2017, cost may become less of a barrier to prescribing PrEP. Specific education about PrEP for primary care providers should address the CDC guidelines, pharmacology, misunderstandings about drug resistance, side effects, cost and insurance, and follow-up and monitoring. Risk compensation (e.g., decreased use of condoms) during PrEP use has varied in clinical studies (Golub, Gamarel, Rendina, Surace, & Lelutiu-Weinberger, 2013; Grant et al., 2014; Liu et al., 2013; Marcus et al., 2013; Mugwanya et al., 2013). Accordingly, providers should be educated about the importance of talking with patients about the need to continue risk reduction behaviors before prescribing PrEP (Storholm, Volk, Marcus, Silverburt, & Satre, 2017). Finally, education in the clinical setting may not be enough to increase prescriptions for PrEP. Professional organizations should work to develop education opportunities to help providers increase PrEP prescription.

Strengths and Limitations of Reviewed Studies

Main limitations of the studies included in this review were the quality of evidence and the potential for biased results. Providers with knowledge of and interest in PrEP may have been more likely to participate in the studies, shifting the results more positively. Additionally, 3 of the 11 studies were conducted in the state of Massachusetts (Krakower et al., 2014; Krakower et al., 2015; White et al., 2012). Two studies used Infectious Diseases Society of America’s membership to recruit participants, although one limited recruitment to Massachusetts residents only (Karris et al., 2014; White et al., 2012). Hence, some study samples may have had overlapping participants. The majority of studies lacked national representation of providers, which limited generalizability of findings to the broader population of providers in the United States. Finally, a surprising finding of our review was that provider comfort and ease in initiating conversations regarding sexual behavior, an oftentimes-sensitive subject, was not explored in the majority of studies.

The studies in our review had several strengths. First, most studies achieved large sample sizes, increasing the chances that the effects seen were valid. A few studies compared primary care providers to specialty providers (Bacon et al., 2017; Hakre et al., 2016; Krakower et al., 2015; Petroll et al., 2016; White et al., 2012). Those studies highlighted gaps in knowledge and attitudes related to PrEP prescription, particularly among primary care providers.

Strengths and Limitations of Our State-of-the-Science Review

Our review synthesized the literature related to explicating provider-level factors that influence the prescription of PrEP. Compared to past reviews, this is the first review to specifically focus on provider-level factors. The synthesis of provider knowledge and attitudes in the qualifying studies enabled us to identify factors that could be targeted in future intervention studies to promote the PrEP prescription. Furthermore, we used a systematic approach to rate the quality of the evidence, which allowed us to consider findings within the context of the studies’ scientific rigor. The use of three independent reviewers strengthened the reliability of judgments made while rating the evidence.

The findings of our review should be considered in the context of the limitations. First, the review included only peer-reviewed literature and excluded any grey literature. This may have limited the number of articles that addressed provider-level factors, potentially reducing the ability to produce more generalizable findings. Additionally, the CDC guidelines were identified as a potential factor impacting the prescription of PrEP, which emerged during the literature search and appraisal. Further research is needed to determine the influence the CDC guidelines may have had on the prescription of PrEP. Finally, studies were confined to the United States, with the exception of one study that included participants from Canada (Karris et al., 2014). This may limit generalizability beyond a national level.

Conclusion

The findings of our literature review suggest that while providers are aware of PrEP, training and increased knowledge related to prescribing is desired. Continued success, implementation, and adoption of PrEP will require increased education and training for primary care providers in order to improve knowledge about the CDC guidelines, address perceived barriers to prescribing, and alleviate concerns about safety, efficacy, and patient adherence. Ultimately, by exploring social cognitive factors that influence the intention and behavior of prescribing PrEP, we hope to contribute to the small body of literature that addresses these provider-level factors. Our findings could be used to inform the design and conduct of future studies to facilitate PrEP prescription adoption.

Key Considerations.

  • Provider knowledge continues to be greater among HIV specialists and infectious disease providers, compared to primary care providers.

  • Perceived barriers to the prescription of preexposure prophylaxis (PrEP) include logistical concerns (e.g., cost, insurance coverage), and perceived harms include adherence issues, drug resistance, side effects, and an increase in risk behavior profiles.

  • More robust, high-quality research is needed on the role of primary care providers in prescribing PrEP. Future correlational and intervention studies are needed to address barriers to the prescription of PrEP.

  • Theoretical models of behavior should be incorporated into future studies to facilitate comparisons of findings across this body of emerging literature.

Acknowledgments

This study was supported by the Penn Center for AIDS Research: P30-AI-045008.

Footnotes

Disclosures

The authors report no real or perceived vested interests that relate to this article that could be construed as a conflict of interest.

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