Where Do Health Professions Students Learn About Pre-exposure Prophylaxis (PrEP) for HIV Prevention?

Abstract

HIV pre-exposure prophylaxis (PrEP) is critical for ending the HIV epidemic, and a necessary part of health professions education. We present data from a US survey study (N = 2085) about educational experiences (coursework and extracurricular), in which medical, physician assistant, nursing, and pharmacy students received training about HIV risk factors and PrEP. We found a discrepancy between the percentage of courses covering HIV risk factors (84.7%) compared to PrEP (54.6%) for all students (P < .001), and specifically among final-year students (92.0% vs. 59.7%; P < .001). Pharmacology courses were the most common exposure to PrEP (46.0%), and 61.3% of students were introduced to PrEP through an extracurricular experience. Health professions education must present HIV risk factors in conjunction with PrEP.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-021-01265-3.

Background

HIV prevention is at a critical juncture, specifically due to the approval of emtricitabine/tenofovir (TDF/FTC) and emtricitabine/tenofovir alafenamide (TAF/FTC) for use as pre-exposure prophylaxis (PrEP) [1]. Daily, oral PrEP with TDF/FTC is up to 99% effective at preventing HIV when taken daily [1]. The US Preventive Services Task Force recommends daily PrEP for all patients with HIV risk factors, including men who have sex with men, people who inject drugs, and heterosexual men and women [2]. Previous work has illuminated that many healthcare providers are unaware of PrEP for HIV prevention which creates a major barrier to decreasing HIV incidence in the USA [3–7]. This means education about HIV must include content about PrEP to ensure future clinicians are prepared to initiate proper preventive counseling in clinical practice.

Despite the recognized need to improve PrEP education among healthcare providers, little is known about the current state of education about PrEP in health professions education programs. A limited body of work has identified knowledge gaps regarding PrEP among health professions students, including medical and pharmacy students [8, 9]. In our previous work, we have described PrEP education content (e.g., safety, effectiveness) and identified disparities in health professions education about PrEP and HIV risk factors across regions throughout the USA [10]. We have also examined students’ knowledge and confidence regarding PrEP, finding that nearly 20% of students was unaware of PrEP, and 30% reported low confidence counseling patients about PrEP [11].

Here we build on our previous work and describe the sources from which students received education about PrEP, including both sources within and outside of academic programs. To better understand PrEP education gaps, we compared students’ reported exposure to training about HIV risk factors to exposure to training about PrEP for HIV prevention within 14 academic courses and 5 health professions programs in the USA.

Activity

We conducted a cross-sectional survey study regarding health professions PrEP education, specifically the educational experiences in which students learned about PrEP and HIV risk factors. Description of survey methods and results pertaining to other survey findings involving other variables have been previously published [10, 11]. An online survey was distributed to a cross-sectional sample of health professions students in the USA between November 2018 and July 2019. Students were identified through partnership with national student professional societies. The survey was administered to future prescribers (medical [MD/DO]/physician assistant students), future nurses (BSN students), and future pharmacists (PharmD students) who were presently enrolled in health professions programs throughout the USA. The survey was administered via Qualtrics® (Provo, UT). The survey instrument is attached as Supplementary Appendix 1.

To evaluate sources of PrEP-related education, we asked students to indicate the first setting in which they learned about PrEP from a list of curricular and extracurricular choices. We also asked students to indicate the courses/clerkships in which they received training about PrEP and those in which they received training about HIV risk factors using a separate check-all-that-apply question for each. The HIV risk factor question was used as a comparison point to identify courses in which HIV risk factors were covered but PrEP was not.

McNemar’s test was used to compare the proportions of students who received training about HIV risk factors to the proportion who also received training about PrEP. Mean numbers of courses with exposure to training about HIV risk factors were compared to the mean number of courses with exposure to training about PrEP using paired-samples t-tests. Comparative analyses were repeated with the subset of students who had advanced to the final-year of their program (n = 586) and thus would likely have completed all coursework. We also completed a sub-group analysis of future prescribers (n = 1,051). Analysis was completed using IBM SPSS (Armonk, NY).

Results

Demographics and Initial Source of PrEP Training

Overall, 2085 students completed the survey (response rate = 2.4%). Demographics of the sample are provided in Table 1. Comparison of sample demographics to national demographics is presented in Supplemental Table 1. In total, 38.7% of students indicated first learning about PrEP for the first time in their academic program, while 61.3% were introduced to PrEP through an extracurricular experience (Fig. 1A). The most commonly identified extracurricular experience was media (18.3%), including advertisements and social media.

Table 1.

Demographics (N = 2,085)

Professional group	N	%
Future prescribersa	1,051	50.4
Future nurses	741	35.5
Future pharmacists	293	14.1
	M	SD
Age	28	8
Gender	n	%
Male	499	23.9
Female	1,557	74.7
Transgender/Other	29	1.4
Sexual orientation
Heterosexual	1,675	80.3
Gay	181	8.7
Bisexual	161	7.7
Other	68	3.3
Year In training
1st Year	436	20.9
2nd Year	636	30.5
3rd Year	427	20.5
4th Year & Up	586	28.1
Race
African-American (Black)	163	7.8
Caucasian (White)	1,388	66.6
Hispanic/Latino/a/x	152	7.3
Native American	18	0.9
Asian	259	12.4
Other	105	5.0
Region
South	733	35.2
Northeast	336	16.1
West	416	20.0
Midwest	600	28.8

^aAllopathic medical (n = 591), osteopathic medical (n = 316), and physician assistant (n = 144) students

Fig. 1.

A Comparing the percentage of students who indicated first learning about PrEP across specific settings, with the majority indicating their introduction to PrEP was in a course in their academic program with the remaining students learning about PrEP from an extracurricular source. B Comparing the percentage of students who indicated they had received training about HIV risk factors vs. PrEP during their health professions program, as indicated by exposure to each topic at least once during a course/clerkship. Across all student groups, the percentage of students who indicated curricular exposure(s) to education about HIV risk factors was higher than the percentage who also reported curricular exposure to training about PrEP. C The most frequently reported course where students were exposed to educational content about HIV risk factors was microbiology/immunology, while a smaller number of students reported also being exposed to content about PrEP in this course. A similar gap between HIV risk education and PrEP education was identified in other courses. Note: Differences in exposure between courses may be driven in part by differences in the percentage of students who participated in these courses. *P < .01; **P < .001

Training

Overall, 84.7% of students reported learning about HIV risk factors in their coursework and/or clerkships, compared to 54.6% who reported learning about PrEP (${\chi }_1^2$ = 544.5, P < 0.001) (Fig. 1B). The percentage of students who reported learning about HIV risk factors was higher than the percentage who reported learning about PrEP for HIV prevention among future prescribers (83.9% vs. 40.0%; ${\chi }_1^2$ = 199.7, P < 0.001), future nurses (86.9% vs. 40.4%; ${\chi }_1^2$ = 326.0, P < 0.001), and future pharmacists (81.9% vs. 71.0%; ${\chi }_1^2$ = 20.9, P < 0.001).

The same pattern of findings emerged when considering only those students who were in their final phase of training. Specifically, the percentage of final-year students who reported learning about HIV risk factors was greater than the percentage who reported learning about PrEP in the full sample (92.0% vs. 59.7%; ${\chi }_1^2$ = 170.7, P < 0.001), and among final-year future prescribers (92.0% vs. 66.0%; ${\chi }_1^2$ = 39.1, P < 0.001), future nurses (90.1% vs. 46.4%; ${\chi }_1^2$ = 123.6, P < 0.001), and future pharmacists (97.9% vs. 90.4%; ${\chi }_1^2$ = 4.73, P = 0.02). Finally, the same trend remained for the subgroup analysis of only future prescribers, including MD students (86.3% vs. 59.6%, ${\chi }_1^2$ = 113.0, P < 0.001), DO students (82.0% vs. 54.7%, ${\chi }_1^2$ = 68.2, P < 0.001), and PA students (89.6% vs. 73.6%, ${\chi }_1^2$= 15.6, P < 0.001) (Supplemental Fig. 1A-C).

Coursework

Figure 1C presents exposure to training about HIV risk factors and PrEP in specific courses. Microbiology/immunology and pharmacology were the courses in which training about HIV risk factors and PrEP was received most frequently. In microbiology/immunology courses, 56.2% of students indicated receiving training about HIV risk factors and 28.0% of students indicated learning about PrEP. In pharmacology courses, 43.9% of students reported receiving training about HIV risk factors, and 46.0% reported training about PrEP.

Overall, the mean number of courses in which students were exposed to training about HIV risk factors was 2.89 (SD = 1.69; median [Med.] = 2.00), while the overall mean number of exposures to training about PrEP was 2.02 (SD = 1.35; Med. = 1.00, P < 0.001). Among future prescribers, the mean number of courses with exposure to HIV risk factors was 3.12 (SD = 1.81; Med. = 2.00), whereas the mean number with exposure to PrEP was 2.13 (SD = 1.42; Med. = 1.00, P < 0.001). Future nurses reported a mean number of 2.84 (SD = 1.54; Med. = 2.00) course exposures to HIV risk factors and a mean of 1.95 (SD = 1.28; Med. = 0.00) course exposures to PrEP (P < 0.001). Future pharmacists reported a mean number of 2.25 (SD = 1.35; Med. = 1.00) courses with exposure to HIV risk factors, and a mean number of 1.81 (SD = 1.19; Med. = 1.00, P < 0.001) courses with exposures to PrEP.

Final-Year Student Subgroup Analysis

Subgroup analysis was also performed on the course exposure data for only those students in the final year of their training (n = 586). The overall mean number of courses in which final-year students reported exposure to training about HIV risk factors was 3.12 (SD = 1.73; Med. = 3.00), while the mean number of courses with exposure to training about PrEP was 2.26 (SD = 1.54; Med. = 2.00, P < 0.001). Among final-year future prescribers, the mean number of courses with exposure to HIV risk factors was 3.91 (SD = 1.95; Med. = 3.00) and the mean number with exposure to PrEP was 2.71 (SD = 1.81; Med. = 2.00, P < 0.001). Final-year future nurses reported a mean number of 2.80 (SD = 1.42; Med. = 3.00) curricular exposures to HIV risk factors and a mean of 1.97 (SD = 1.36; Med. = 2.00, P < 0.001) exposures to training about PrEP. Final-year future pharmacists reported a mean number of 2.54 (SD = 1.44; Med. = 2.00) courses with exposure to HIV risk factors, and a mean number of 2.11 (SD = 1.26; Med. = 2.00, P < 0.001).

Discussion

PrEP is an essential component of the federal Ending the HIV Epidemic plan [12]. With over 30,000 new HIV diagnoses per year, scale up of PrEP is critical to slow and ultimately end HIV transmission [13]. To ensure this preventive therapy reaches people at risk for HIV, health professions education must provide training about PrEP for HIV prevention. Our results suggest that courses covering HIV often do not cover PrEP for HIV prevention.

We found great diversity among the courses in which students reported learning about PrEP and HIV risk factors, which is encouraging. This diversity of curricular experiences also indicates that there are a number of opportunities in which education about PrEP may be added to augment training about HIV risk factors. Overall, the mean numbers of curricular exposures to training on HIV risk factors were greater than mean curricular exposures to PrEP among future pharmacists, future prescribers, and future nurses, including those in their final-year of training. Finally, we observed stability in these trends when restricting analysis to only those students who were future prescribers. This group is key in ongoing efforts to increase PrEP prescription given their interface with patients and prescriptive authority to initiate a PrEP prescription for a patient while managing follow-up care. Together, these results indicate that students may be receiving incomplete education about HIV, learning about risk factors without concurrently learning about HIV prevention with PrEP, and subsequently entering practice with this knowledge deficit.

Limitations

We acknowledge several limitations of the present analysis. First, the overall low response rate of the survey (2.4%) could limit the generalizability of our findings. Response rates in PrEP-related survey research among health professionals have been highly variable and generally suboptimal, with the majority falling within the poor-to-fair range (i.e., < 30%) [14]. Although low response rates may heighten concern about self-selection bias, our sample composition is demographically similar to health professions students nationally, with a slight over-representation of female respondents and more racial diversity (Supplemental Table 1). Generalizability may also be limited to the extent that our sample is biased towards students with an existing interest in the subject material who self-selected into the study. Results may also be biased by students who remembered more details about their training due to this interest in the subject matter.

Additionally, students’ self-report of receiving training about PrEP or HIV risk factors is an imperfect indicator of actual coverage of the topics in the courses, as reports may be influenced by students’ attendance or memory of courses. Regarding the data describing courses in which students received training about HIV risk factors or PrEP, it is important to note that the data do not describe the percentage of students who completed each of the indicated courses; this additional information could offer a more complete picture in future studies. Finally, the students in this survey were still enrolled in their health professions education program and thus may receive initial or additional education about PrEP or HIV risk factors in later coursework. It was for this reason that we repeated all analyses with only the subset of participants in their final-year of their programs, after coursework had been completed. Finally, the percentage of students who indicated learning about HIV risk factors may be somewhat elevated due to the assumed, higher public knowledge of HIV risk relative to PrEP. Furthermore, HIV risk factors may have been covered in education prior to health professions training; however, we attempted to mitigate this by asking students to only consider courses in their health professions education. The accuracy of students’ recall of PrEP and HIV risk factors being covered in a course could be influenced by prior knowledge/education about those topics as well as content emphasis and assessment within the course. Future work is needed to characterize the relationship between specific educational experiences and knowledge and skills about PrEP and HIV risk factors among health professions students. Curriculum mapping and tracking of achievement of core competencies regarding PrEP and HIV risk factors may provide this insight.

In conclusion, the results from this national, multidisciplinary survey suggest education about HIV risk factors and PrEP for HIV prevention does not appear to be matched. This may represent incomplete education about HIV, as education about risk factors for HIV without concurrent education about the effective preventive measures does not represent the state of the HIV epidemic in the era of biomedical prevention. Educators must ensure HIV curricula are comprehensive and up to date, including PrEP, in order to prepare the next generation of healthcare providers to fulfill their roles in reducing HIV incidence.

Supplementary Information

Below is the link to the electronic supplementary material.

Funding

The authors wish to thank Rosalind Franklin University for their support of this research. No additional funding was received to support this work.

Declarations

Ethical Approval

This study was approved by the Institutional Review Board of Rosalind Franklin University.

Informed Consent

Informed consent was received from all participants prior to participation in the study.

Conflict of Interest

SRB, SSG, and TJB have received unrestricted research funding from Gilead Sciences for research unrelated to the present work. SKC has previously received unrestricted project support from Gilead Sciences for unrelated projects. The authors declare that they have no other conflicts of interest to disclose.