Delivering PrEP to Adults with “Low” or “No” HIV Risk and Youth: Experiences and Perspectives of PrEP Providers

Abstract

Health care providers have an important role to play in expanding PrEP uptake to populations disproportionately burdened by HIV infection. In this study, in-depth, semi-structured qualitative interviews were conducted with 20 PrEP providers in Los Angeles, California to explore their experiences and perspectives prescribing PrEP. Overall, the findings indicate that providers generally adhered to US CDC clinical guidelines in determining PrEP eligibility. However, they also identified special considerations with respect to adults with “low” or “no” HIV risk. Three themes were developed from the data related to the delivery of PrEP to such individuals: 1) patients may not disclose sexual behaviours; 2) patient autonomy and agency; and 3) the importance of PrEP in gay male monogamous relationships. Two additional themes were identified related to prescribing PrEP to young people under the age of consent: 4) the need for more PrEP and sexual health education with youth and 5) challenges in providing PrEP to youth without parental consent. Findings highlight the importance of providing PrEP to patients who could potentially benefit from adoption, whether or not they present with clear behavioural indicators for PrEP. Providers should also consider the potential barriers to delivering PrEP to youth to ensure successful adoption among members of this population.

Introduction

Health care providers can play an important role in facilitating Pre-Exposure Prophylaxis (PrEP) adoption among marginalised populations disproportionately affected by HIV (Calabrese, Krakower and Mayer 2017; Przybyla, LaValley and St. Vil 2019). PrEP is a proven biomedical HIV prevention strategy that involves once daily dosing of an antiretroviral medication to prevent infection (Grant et al. 2010; Thigpen et al. 2012; Baeten et al. 2012). The US Centers for Disease Control and Prevention (CDC) has established clinical guidelines for administering PrEP to high-risk individuals (CDC 2018). Among men who have sex with men, indicators for PrEP include having sex with a male partner in the past six months or being in a non-monogamous partnership with an HIV-negative man. Men who have sex with men must also report having either condomless anal sex (receptive or insertive) or a bacterial sexually transmitted infection in the past 6 months to be eligible for PrEP. Although the effectiveness of PrEP has not yet been proven definitively in clinical trials with transgender women, the CDC recommends PrEP for all persons at risk for acquiring HIV sexually, including transgender persons (CDC 2018).

Prior research has identified important limitations in using the CDC clinical guidelines in determining PrEP eligibility. Primary among them is the fact that they rely too heavily on self-reported sexual risk behaviours (Calabrese, Krakower and Mayer 2017). Calabrese, Krakower and Mayer (2017) further suggest that some patients (e.g. Black men who have sex with men) may feel uncomfortable disclosing their sexual risk behaviours with health care providers, due in part to the belief that providers may harbour negative attitudes. The resulting lack of disclosure regarding one’s sexual risk behaviours may therefore affect a provider’s ability to make an accurate assessment of HIV risk. Another important limitation to the CDC guidelines was identified by Cornelisse et al. (2018). In their study, participants who did not meet PrEP eligibility requirements at enrolment (20.7%), but who were otherwise connected to PrEP services by their provider, had a high prevalence of sexually transmitted infections at follow-up (7.1%). This suggests that behavioural risk behaviour assessments alone may not always identify those who could benefit from PrEP. Informed by this, this study sought to explore the experiences and perspectives of PrEP providers in Los Angeles County, California to inform changes in PrEP delivery services to ensure that all patients who could potentially benefit from PrEP are able to access the medication. Los Angeles County is the second largest HIV epicentre in the USA, with the majority of HIV cases among racial/ethnic, gender and sexual minority populations (LAC DHSP 2018).

Methods

Participants and procedures

A convenience sample of health care providers prescribing PrEP was recruited between May 2018 and October 2018 to complete in an in-depth, semi-structured telephone interview. In order to participate, providers had to be 18 years of age or older and had to be a health care provider (e.g. medical doctor, nurse practitioner or physician assistant) currently prescribing PrEP. Participants were recruited by email invitation from a listserv of PrEP providers in Los Angeles County or through community agency referrals, and then screened over the phone by the study project director (ON). Written informed consent was obtained via email from each provider before initiating any study procedures. Providers were then asked to complete a brief pre-interview survey to gather information on their sociodemographic characteristics, the health facilities where they were employed, and percent estimates of the sociodemographic characteristics of their PrEP patient population. Recruitment was closed when data saturation was reached (i.e. interviews provided no new information). Providers were compensated $100 for their participation.

A semi-structured interview guide was developed to explore providers’ perspectives and experiences prescribing PrEP to adult populations. As part of the interview, providers were asked to describe: 1) the populations that should be targeted for PrEP, and 2) whether they adhered strictly to US CDC guidelines in determining PrEP eligibility. If providers indicated not adhering to the guidelines, we probed as to how they diverged from CDC protocol. Providers were also asked if they would prescribe PrEP to gay men in HIV-negative seroconcordant monogamous relationships, and then explored the reasons why or why not. This specific interview topic was informed by our prior research with Black and Latino gay and bisexual PrEP users (Brooks et al. 2019a; Brooks et al. 2019b). In particular, Black and Latino gay and bisexual men who were in a relationship reported having encounters with a primary care physician who discouraged their use of PrEP, and instead recommended that they practise consistent condom use or maintain monogamy in their relationship. Because this study occurred immediately following the US Food and Drug Administration’s approval of Truvada as PrEP for adolescents (FDA 2018), providers were also asked about their level of comfort with prescribing PrEP to young people (i.e. persons under 18 years of age). As a probe, they were then asked to describe how conversations about PrEP might be different with youth than with the adult patients they serve. Interviews were audio recorded and lasted 60–90 minutes. All interviews were then transcribed verbatim and checked for accuracy by three research team members. Providers were assigned a unique participant identification number to maintain confidentiality. The Institutional Review Board of the University of California, Los Angeles approved all study procedures and materials.

Data analysis

Interview transcripts were iteratively coded and analysed using a thematic analysis approach (Braun and Clarke 2006). We began with the creation of a coding scheme to help guide our review of the transcripts. Initial codes were developed using an iterative process involving a review of the interview guide and interviewer field notes, and a line-by-line review of the interview transcripts. The study team met weekly to refine the coding scheme by adding or deleting codes, updating code descriptions, and identifying quotes that best represented the codes. Once consensus was reached on the coding scheme, a subset of codes was selected to test for inter-coder reliability (ICR). Two research team members independently coded two randomly selected transcripts and an average ICR score was computed (Cohen’s kappa coefficient, k = 0.93). Final codes were entered into ATLAS.ti (version 8.3.20.0) and attached to their associated quotations for all transcripts.

Once initial coding was completed, the study team reviewed the data exports and developed an additional coding scheme to organise the data into broader categories related to the experiences and perspectives of providers in delivering PrEP to patients. These broad categories were then refined to identify emerging themes related to the primary considerations or concerns providers noted when delivering PrEP to adults with “low” or “no” HIV risk and youth, respectively. Themes were selected based on the frequency and depth with which they were discussed in the transcripts.

Results

A total of 23 providers were contacted to participate in the study (2 were lost to follow-up before they were screened). Of those, 21 were screened eligible and 20 completed the interview. Provider sociodemographic characteristics appear in Table 1. Overall, half identified as members of racial/ethnic minorities and sexual minorities, all identified as cisgender, and the majority (70%) reported working for a Federally Qualified Health Centre. The average length of time prescribing PrEP was a little over two years. Based on provider estimates, on average, approximately 90% of the patients they served were cisgender men, 80% were gay/homosexual, 65% were racial/ethnic minorities, with more than half (55%) being Black and Latinx, and a small proportion (8%) being transgender women. This suggests that the majority of their patients were racial/ethnic, gender, and sexual minority individuals.

Table 1.

PrEP Provider Demographics (N=20)

Characteristic	N (%) or M, SD
Provider Demographics
Age (in years)	M=39.5, SD=11.4
Racial/Ethnic Identity
White/Caucasian	9 (45.0)
Latino/a	4 (20.0)
Asian/Pacific Islander	3 (15.0)
Bi/Multi-racial	2 (10.0)
Black/African-American	1 (5.0)
Egyptian or Middle Eastern/North African	1 (5.0)
Gender identity
Cisgender Woman	10 (50.0)
Cisgender Man	10 (50.0)
Sexual orientation
Straight or Heterosexual	10 (50.0)
Gay/Homosexual	8 (40.0)
Other1	2 (10.0)
Facility Type
Federally Qualified Health Centre	14 (70.0)
University Based Clinic	2 (10.0)
Health Maintenance Organisation	2 (10.0)
Community-Based Organisations	1 (5.0)
Hospital	1 (5.0)
Provider Type/Profession
Nurse Practitioner	10 (50.0)
Medical Doctor	6 (30.0)
Physician Assistant	4 (20.0)
Length of time providing PrEP (in years)	M=2.2, SD=1.6
Average number of PrEP patients seen last week (N=19)2	M=14.8, SD=17.1

¹Other responses include lesbian and queer.

²Only includes providers who responded to the question about average number of PrEP patients seen last week.

When questioned about their PrEP prescribing practices, providers described a range of factors that influenced their decision to offer PrEP to their patients. For example, as part of standard practice, most providers indicated using CDC clinical guidelines to determine PrEP eligibility for most patients. This included recommending PrEP to patients who report elevated sexual risk behaviour (e.g. multiple partners, condomless sex, HIV-positive partner, partners of unknown HIV status, and injection drug use). However, we also discovered that providers diverged from CDC clinical guidelines with patients who were perceived as having “low” or “no” risk for HIV based on reported sexual behaviour. In these instances, providers considered other factors to determine the need for PrEP. They also described potential challenges to prescribing PrEP to youth.

Three themes were developed from the data related to the special considerations that providers made for adults with “low” or “no” HIV risk. These included 1) the fact that patients may not disclose sexual risk behaviours; 2) respect for patient autonomy and agency; and 3) the perceived importance of PrEP in gay male monogamous relationships. Two additional themes were identified related to potential challenges when prescribing PrEP to youth, which included 4) the need for additional PrEP and sexual health education with youth and 5) special challenges of providing PrEP to young people without parental involvement.

Special Considerations when Prescribing PrEP to Adults with “Low” or “No” HIV Risk

Patients may not Disclose Sexual Risk Behaviour

Providers indicated that some patients may not be comfortable disclosing or discussing their sexual risk behaviour, particularly during an initial PrEP consultation visit.

Depending on my comfort with, or how I felt they were about being honest with me on the first visit, which I don’t expect you to be honest with me 100% on the first visit, I would tell them who it [PrEP] is for, when its recommended….

(Latina, NP, 1.5 years prescribing PrEP)

There was also an acknowledgment that some patients who do not currently present with behavioural indicators for PrEP might be planning for future risks, and therefore, should be provided with the medication.

There has been a couple of patients that say they’re not really at risk of HIV but they still would like to take PrEP. So, of course, I talk to them more about that and maybe they’re not telling me something or maybe they’re planning on having more sexual exposures in the future, but generally I just give them PrEP. I don’t say, “You’re not at risk, you can’t have it.” […] I don’t so much assess risk. I just give it to anybody who wants to take it and if they don’t want to take it, then I also confirm, with follow-up questions, to see if they are at a higher risk of getting HIV, and if they are, then I bring it up again.

(White Man, MD, 2 years prescribing PrEP)

In addition, providers viewed the provision of PrEP, particularly in the context of non-disclosure of sexual risk behaviour, as an opportunity to build a trusting relationship with the patient and to keep them engaged in healthcare.

I always write for it and I take it as an invitation to have a much further relationship with this person to see what [the motivation is behind the request]. And some people don’t tell you what they’re up to and don’t feel comfortable with doing it. You don’t press… So, I guess my thinking diverges in that way [from the CDC guidelines] because the prescription is really straightforward, but I’m more interested in that person’s story and the relationship that can be built with that person with PrEP as the excuse… And it’s good to support that person and build a relationship with them to kind of get them looped into medical care.

(Latino, NP, 5 years prescribing PrEP)

Patient Autonomy and Agency

A related theme was an acknowledgement of patients’ need for autonomy and personal agency in determining the appropriateness of PrEP. While service providers acknowledged patients’ capacity to make responsible decisions about their sexual health and would therefore prescribe PrEP, they still felt a professional responsibility to ensure that patients understood what was involved in taking the medication (e.g. risks and benefits, side effects, importance of adherence).

I think I do adhere to the [CDC] guidelines, but I’ve also been prescribing PrEP if there are individuals who ask for it and don’t necessarily meet all the criteria or meet criteria based on CDC guidelines. I have learned from my previous clinician educators that if someone is asking for PrEP and they want it, it’s not my job to say that they shouldn’t be on it; it’s about describing the risks and benefits of the medication and having the patient come to a decision with me.

(White Man, MD, 3 years prescribing PrEP)

I try, yes, in the spirit of things [to adhere to the CDC guidelines]… So, kind of from the medical side, like testing and all that stuff, I don’t diverge much… The part that I probably diverge is that they have the three risk categories (high risk, intermediate, low). I’m kind of probably more if the patient wants it, I’ll just give it to them as long as they can agree to the issues of compliance and if they understand what they’re doing.

(API Man, MD, 6 years prescribing PrEP)

Importance of PrEP in Gay Male Monogamous Relationships

Another theme concerned an understanding by providers that gay men in HIV-negative seroconcordant monogamous relationships might still benefit from using PrEP. Providers understood that a request for PrEP in this context may be related to a deeper set of issues, concerns or fears a patient has about his relationship, which he might not wish to discuss in detail with a provider. In particular, a patient might be worried that he or his partner may not be faithful and, as a result, expose the other to HIV infection.

If someone’s asking for PrEP, then my fear is twofold: the patient (whether they’re straight or gay) is either not being faithful to their partner or the patient in front of me is fearful that their partner’s not being faithful to them, in which case, in my mind, that’s a good idea to put somebody on PrEP.

(White Man, MD, 4 years prescribing PrEP)

Sometimes I think us providers, we don’t hear the whole story and usually if the patient is requesting PrEP, they might know something [about their partner] or know something about themselves that they don’t necessarily want to share with us or that they want to keep private. But they might need it, so I would feel comfortable with it.

(Bi/Multi-Racial Woman, NP, 1.5 years prescribing PrEP)

There may also be other undisclosed risk factors present in the relationship that providers are not privy to, or that patients do not wish to disclose for fear of being judged or stigmatised (e.g. involvement in sex work or the porn industry, periods of openness in a monogamous relationship).

So, my experience in this field is that there aren’t that many [gay] monogamous relationships. Many, you know, some of them they may go on, maybe on vacation and play, or they play all the time.

(Latina, NP, 1.5 years prescribing PrEP)

I always wonder, “Okay, well, the person says they’re in a mutually monogamous relationship and its seroconcordant, so there shouldn’t really be any risk there. But what if one day they’re not mutually monogamous or what if somebody cheats or what if there is some other social history component there that I haven’t been able to tease out – like, the partner is a sex worker or does porn or some other issue that might also put them at risk for HIV.

(White Man, PA, 1 year prescribing PrEP)

While the decision to initiate PrEP ultimately rests with the patient, providers recognised that gay men in monogamous relationships might still be at substantial risk of acquiring HIV.

I do have patients who are in monogamous relationships and unfortunately there are many reports of people going outside of relationships and then contracting HIV and then giving it to their partners. So, I think, observationally, I have been in those situations… I don’t push it necessarily if they’re saying they are in a monogamous relationship, because that’s me just me jumping to conclusions… But I [do] have plenty of patients that are in “monogamous relationships” that are both on PrEP.

(White Woman, PA, 1.5 months prescribing PrEP)

Potential Challenges when Prescribing PrEP to young people

The Need for More PrEP and Sexual Health Education with Young people

Providers expressed a willingness to prescribe PrEP to youth who report sexual risk behaviours consistent with CDC clinical guidelines. However, some identified additional steps that may be required when providing PrEP to youth. For example, a common sentiment shared by providers was the possibility of needing to begin conversations with some basic information about sex, sexual exploration, and the behaviours that put persons at risk for HIV infection.

I think that, were I to do it [prescribe PrEP to youth], it would probably be sort of gauging the education – I mean, I think I would maybe be even more basic. I would probably talk to them about how they have a long life ahead of them, how, at their age, it’s normal to experiment sexually, that sometimes we can end up in situations where the moment sweeps you up and you’re not really thinking straight, and that this is a really great way to prevent HIV in case something happens that you can anticipate.

(White Man, NP, 0.5 years prescribing PrEP)

Providers also suggested the need to engage young people in more in-depth conversations to ensure that they comprehend what it means to use PrEP and to stress the importance of adhering to the medication.

I think it [the conversation about PrEP] would be very similar, but just having more re-instruction, repeating it, and maybe having them repeat it back to me. And just [making] sure they grasp everything and the importance of adherence, for example – making a little bit more sure that that goes through and that they’re grasping everything, maybe that would make a difference. Maybe having them visit the office more often than someone who was over the age of 18.

(Latina, NP, 0.25 years prescribing PrEP)

In addition, providers further suggested that young people may be less fearful of HIV because they lack the personal experiences of the devastating impact of the early years of the epidemic. Because of this, some providers noted how they might adopt a more paternalistic approach in their conversations with young people about HIV and PrEP.

I think there’s a huge difference even from the age of 20s to 40s discussing PrEP just because people who have lived through the HIV epidemic and have loss lots of folks and friends and family. You know, the younger folks, I really like to have a little more of a – I don’t want to use this word – but more of a stern conversation and say, “I know you’re really young, but these decisions that you’re making now will affect your life forever, so you might want to consider this medication as a prevention strategy if you’re having sex without condoms.” And unfortunately, our sexual education is very poor, specifically in the LGBT population in schools and what not, so my experience with even people who are 18 is that they’re very high risk for HIV.

(White Woman, PA, 1.5 months prescribing PrEP)

Challenges of Providing PrEP to Youth without Parental Involvement

Also discussed were additional challenges that might arise when prescribing PrEP to youth. For example, providers described how it accessing PrEP might be difficult for young people who attempt to access it without parental consent or knowledge. This could be especially true for young people who are living at home and/or covered by their parent’s health insurance.

We would have to address the fact that they have parents that may or may not be involved in it and then also due to their insurance they may or may not find out – likely they’ll find out. So, then we have to kind of just talk about the logistics of that.

(API Man, MD, 6 years prescribing PrEP)

The other thing is that less than 18, the thing you have to be most careful about is that they are most likely still living with their parents. So that adds another dimension of confidentiality.

(White Man, MD, 4 years prescribing PrEP)

There was also concern that a request for PrEP might require young people to have difficult conversations with parents about their sexual behaviours, particularly same sex behaviours. Within this context, a request for PrEP might trigger a negative or stigmatised response from parents based, for example, on the belief that PrEP users are promiscuous and engage in unsafe sexual practices.

The younger population, they may need to talk to their parents. It depends on their circumstance. They may just be recognising that they’re homosexuals, so there’s going to be a lot of psycho-social issues with the PrEP and then the stigma. Maybe they’re using it as a party drug, so only on the weekends when they’re going to parties or something and having very risky behavior.

(Latina, NP, 1 year prescribing PrEP)

Would the parents be involved? That’s a consideration, because they might think that being on the medication is encouraging their child to be promiscuous. And that’s a conversation that a lot of people don’t want to have, as a parent, I think.

(Black Woman, NP, 4 months prescribing PrEP)

Discussion

This study has described the prescribing practices and perspectives of PrEP providers in a high HIV prevalence setting and with a large patient population of racial/ethnic minority gay men. In general, most providers reported adhering to CDC clinical guidelines in determining PrEP eligibility. However, providers also diverged from the CDC guidelines and routinely made special considerations when assessing their patients’ need for PrEP. This included acknowledging that some patients might find it difficult disclosing or discussing their sexual risk behaviours, honouring patient autonomy in PrEP decision-making, and recognising that gay men in HIV-negative seroconcordant monogamous relationships may still benefit from using PrEP. Providers also discussed the potential challenges that might arise when providing PrEP to youth, such as the need for general education about HIV and sexual risk, more in-depth conversations to ensure PrEP literacy, the challenges of maintaining confidentiality, and the difficult conversations youth might need to have with parents in order to receive PrEP. Overall, our findings revealed the varied ways PrEP providers deviate from the CDC’s clinical guidelines and consider other factors when prescribing PrEP.

In this study, providers understood that some patients may not fully disclose or discuss their sexual behaviours with health care providers. While not explored in the current study, prior research has shown that this is particularly true among racial/ethnic minority gay and bisexual men and transgender women. Multiple studies have noted that some Black and Latino gay and bisexual men do not disclose their sexual behaviour or sexual orientation to providers, and that this lack of disclosure can serve as a barrier to being offered PrEP by health care providers (Petroll and Mosack 2011; Bernstein 2008; Lelutiu-Weinberger and Golub 2016; Hoots et al. 2016). Factors that may contribute to a lack of disclosure of same-sex behaviours and acceptance of gay identity include perceived homophobia in communities of colour, machismo/hyper-masculinity, the fear of losing social support, and perceived judgment or stigma from health care providers (Arnold, Rebchook and Kegeles 2014; Murray et al. 2018; Qiao, Zhou and Li 2018; Maloney et al. 2017). In addition, transgender persons may experience a barrier to discussing sexual behaviours with healthcare staff due to a lack of transgender affirming and competent providers (Sevelius et al. 2016). The narratives of providers in this study suggest that the relationship a provider establishes with their patients is key to building more honest and open lines of communication and in supporting patients to remain engaged in medical care. However, to achieve this, providers preparing to deliver PrEP may require LGBTQ and racial/ethnic minority competency training to ensure that they can effectively communicate and engage with racial/ethnic, sexual and gender minority individuals.

Providers also offered insights into their interactions with patients who request PrEP despite not presenting with any behavioural risks for HIV. One example was the need for providers to respect the personal autonomy and agency of patients in their decision-making around PrEP, trusting that they can make informed decisions about their sexual health. This was often associated with providers’ recognition that sexual risk behaviours can change over time, particularly in gay male populations. Previous research has suggested that a range of factors can influence changes in sexual behaviours among gay men, such as their relationship status, financial circumstances, substance use and mental health (Gilkey et al. 2019). To support PrEP uptake, it is important for providers to understand the variability in sexual risk taking among some groups (e.g. gay men) and to recognise that if a patient requests PrEP, but does not currently meet the behavioural requirements for PrEP, they may still benefit from this prevention option given the potential for future risk behaviour.

Another finding from this study was the understanding by providers that gay men in HIV-negative seroconcordant monogamous relationships with no clear indication for PrEP may still benefit from receipt of the medication. This is supported by prior research indicating that up to 68% of gay men who contract HIV do so while in a monogamous relationship (Sullivan et al. 2009). Several factors have been shown to increase HIV risk behaviours in gay male relationships, such as having an older partner, drug use before sex, physical violence or forced sex and relationships lasting longer than six months (Mustanski, Newcomb and Clerkin 2011). It is possible to apply these same considerations to other vulnerable groups who are at substantial risk for HIV infection from a primary partner, such as transgender women of colour. Previous studies suggest that transgender women are more likely to be exposed to HIV and report condomless anal receptive intercourse with primary partners than they are with causal or exchange partners (Operario et al. 2011; Nemoto, Bödeker and Iwamoto 2011). Multiple social and contextual factors contribute to instances of condomless sex between transgender women and primary partners, which include living with the partner, lower self-efficacy in negotiating condoms use, drug use and the desire to have partners affirm their identity as women (Operario et al. 2011; Melendez and Pinto 2007). The use of PrEP in monogamous relationships may therefore lessen the risk of HIV infection and/or address any fears or concerns a patient may have about the potential for infidelity. In counselling patients, providers should discuss the possible consequences and risks associated with forgoing PrEP while in a relationship (e.g. potential exposure to HIV, HIV seroconversion).

The FDA’s expanded approval of Truvada for PrEP to include young people is a promising move toward lowering the rate of HIV infection in this population (FDA 2018), yet the complex nature of initiating and maintaining a PrEP prescription requires additional considerations to ensure its effective use with young people. In this study, providers described challenges that may arise when prescribing PrEP to youth, such as the difficult situation of young people needing to disclose sexual behaviours (e.g. same sex behaviours) to parents, as well as providers concerns about poor medication adherence and retention in PrEP care. To ensure compliance, providers recommended increasing the frequency of medical monitoring visits with youth, instead of the current standard of PrEP care (i.e. once every three months). In addition, findings from Kosciw et al. (2018) and comments from service providers in this study revealed that LGBTQ youth may require general sex education as part of the provision of PrEP because of the lack of LGBTQ-inclusive sex education in schools. Many of these concerns align with findings from other studies assessing providers’ perspectives on providing PrEP to youth (Mullins et al. 2016; Allen et al. 2017).

Service providers also recognised the unique challenges persons under 18 years of age might encounter when trying to access PrEP without parental involvement. Paramount among them is the legality of young people initiating PrEP without parental consent (Mullins et al. 2016; Allen et al. 2017; Culp and Caucci 2013). In California, the site of the present study, youth are able to access HIV prophylaxis (i.e. PrEP) without parental permission. However, there are other US states in which young people are only allowed to receive treatment for sexually transmitted infections without parental consent, but not PrEP (Culp and Caucci 2013; Allen et al. 2017). Providers also recognised that youth may experience unintentional disclosure of their PrEP use to parents through automated insurance benefits statements (e.g. medications covered, purpose of medical visits). This suggests that providers will need to understand the legal and structural issues within their medical facility and state that are associated with prescribing PrEP to youth.

Limitations

These findings should be interpreted within the context of the study’s limitations. We recruited a convenience sample of PrEP health care providers in Los Angeles County. Because of this, these insights may not be generalisable to PrEP providers in other localities. In addition, the providers were primarily sampled from a listserv of PrEP/PEP providers who belonged to a county-wide prevention network. Therefore, these providers may have had a particularly positive outlook toward PrEP and would thus be more willing to write a prescription than providers who were less familiar with the medication. Providers also reported percent estimates of the proportion of their PrEP patients by race/ethnicity, gender identity and sexual orientation, which may be subject to low reliability and validity. Finally, the current study did not fully explore the nuances of providing PrEP to transgender women in the same manner it did with gay men in HIV-negative monogamous relationships. Future research with health care providers prescribing PrEP should focus on the special considerations needed to effectively deliver PrEP to transgender individuals, particularly Black and Latina transgender women.

Conclusion

As HIV prevention efforts continue to facilitate the uptake of PrEP to reduce incident infections, more health care providers will be involved in the delivery of PrEP. As such, we will need to prepare and train these providers on how to deliver PrEP to populations most affected by the HIV epidemic. As the findings of this paper highlight, delivering PrEP involves, in some instances, moving beyond strict adherence to CDC guidelines in determining the need for PrEP. In particular, findings suggest the need for education and training to better prepare staff to serve the sexual health needs of populations most affected by HIV epidemic, such as racial, ethnic, sexual and gender minority populations. Unfortunately, many health education institutions and healthcare facilities are woefully lacking in their ability to prepare health care providers to address the sexual health needs of these populations. It is important that medical education and/or continuing education for health professionals include cultural competency training around understanding, communicating with, and effectively serving racial, ethnic, sexual and gender variant patient populations. Part of this education should include recognising and understanding the reasons for limited or non-disclosure of sexual risk behaviours by these groups (e.g. embarrassment, fear of judgement, medical mistrust and past experiences of discrimination from providers), particularly in the early stages of the physician/patient relationship. Without this knowledge, providers may miss the opportunity to offer HIV preventive health services such as PrEP to populations at greatest risk for HIV infection.

In addition, more education and/or training is needed for addressing the sexual health needs of young people, particularly racial, ethnic, sexual and gender minority youth. Part of this education needs to include an understanding of local and state policies around the types of services youth can receive without parental involvement, and institutional policies and support such as training or resources for providing HIV preventive health services, such as PrEP, to youth. These may include, for example, more frequent monitoring of young patients receiving PrEP, more extensive counselling or education around sexual health, in general, and improving PrEP literacy for young people considering or receiving PrEP. These extra steps may help improve adherence and persistence with PrEP among youth.

In conclusion, medical and other health providers are uniquely positioned to facilitate PrEP uptake in populations disproportionately affected by HIV and may succeed in doing so with proper education, training and support, and cultural humility. In addition, CDC indicators for PrEP initiation and use may need to be modified to include individuals who believe themselves to be at risk without presenting with high risk behaviours given that the disclosure of sexual behaviours can be especially problematic for some populations (e.g. Black and Latino/a gay and bisexual men and transgender women).