Table 2:

Themes and Illustrative Quotes

Domain/Theme	Illustrative Quotes
Provider Knowledge, Attitudes and Belifs about PrEP
Providers believe PrEP is effective but are unsure exactly how effective	“I guess I’ve heard it’s extremely effective. When I say extremely – excuse me, I actually don’t know the exact numbers. But I would imagine based on just memory that probably I’m going to say 75–80% effective.” – High probability, low-prescribing provider (ID 16)
PCPs should be prescribing PrEP	“It’s part of our job as physicians and as PCPs. I don’t think It’s something like special or niche. I think It’s just we’re all trained to be - I mean especially as a primary care doctor part of what we do is disease prevention and health maintenance. And I think this is just - this is just like a huge opportunity to make such a profound impact on somebody’s long-term health and wellbeing by offering them a once-a-day medication that could prevent them from still a very stigmatized lifelong illness. So, to me it just seems like common sense, obvious, easy.” – Low probability, high prescribing provider (ID 07)
Side effects and adherence are concerns, but concerns do not affect prescribing	“Well, I’ve had several people who have asked me for PrEP and we talked about PrEP and they take it for a short period of time because they feel that partner is a risk to them. And then, they have it. And then, they come back again when they get a new partner that they think is at risk for them. And I’m a little bit concerned about the starting and stopping it. Then I’m seeing people wanting to do and also, I think that some of them are using it with only the ones they think are high-risk, but that there may be having other high-risk partners.” – Low probability, high-prescribing provider (ID 15)
Providers have high PrEP knowledge but have some misconceptions	“I’ve heard that it can be used by both men and women to prevent it [HIV]. And that it could be given to women who are prostitutes or have multiple sexual partners, as well as men who have multiple partners and are at risk.” – Low probability, high-prescribing provider (ID 15)
Barriers to PrEP Prescribing
Clinic structure and policies can be barriers to PrEP prescribing	“When a patient has a lot of questions or they’ve never taken it [PrEP] before, I often do refer to my colleague that I referred to earlier. Because he’s just more up to date on it and it’s more of a specialty of his….We’re a small clinic, so I often refer to my colleague who has a larger gay male population in his practice.” – High probability, low prescribing provider (ID 16)
Discomfort discussing sexual behaviors and STI and homophobia inhibit prescribing	“And there’s a lot of physicians who are fairly conservative when it comes to their personal beliefs and values which limits their comfort level in those things. A lot of physicians and providers who don’t feel comfortable talking about sex at all.” – Low probability, high-prescribing provider (ID 11)
Lack of provider knowledge/awareness of/training around PrEP are prescribing barriers	“A lot of providers aren’t educated about PrEP; it is not a typical continuing education topic. Unless people experience it in training programs at their residency, they tend to forgo learning about new topics, and PrEP is relatively new. There is a perception amongst many providers that anything to do with HIV is for an infectious disease specialist, although prevention falls in primary care. Most don’t have experience prescribing PrEP and don’t necessarily want to learn about them, because of potential side effects like nephrotoxicity, or they aren’t sure about complications. There is a perception safe sex and condom use is good enough.” – High probability, low-prescribing provider (ID 14)
Community and provider stigma are barriers to prescribing	“So, I think there’s some people that are concerned about their risk, I think there are some people that are worried that the patients will be stigmatized if they’re on PrEP, so especially in a small town that that could be more of a concern if you have one pharmacy and everybody knows everybody. And I think that’s a bigger issue for smaller town doctors.” – Low probability, high-prescribing provider (ID 09)
Social determinants of health are barriers to patients taking PrEP	“Now, I have to say, I think that It’s expensive. And I think that’s a big problem. And that – that’s a barrier for – because while the Gilead Company and their drug reps maintain that anyone who wants to be on Truvada can get it free, It’s not easy, It’s complicated, there’s lots of paperwork. there’s CAP[community assistance program] – I don’t, you know, you’re familiar with Truvada, so there’s the CAP card that gets you a discount.” – Low probability, high-prescribing provider (ID10)
Complexity and time impede PrEP uptake	“PCPs have too much on their plate or see PrEP as something specialized. Also, PCPs and clinics limit the amount of time physicians spend with patients, which makes time for PrEP discussion challenging. Also, the time for testing and follow up.” – Low probability, high-prescribing provider (ID 05)
Privacy concerns may impede providers’ ability to prescribe PrEP to younger patients	“The other half have their healthcare insurance under their parents. And if we do some testing for sexually transmitted infections, we always tell our students should know the explanation of benefits that their parents may receive could include the fact that they had screening for gonorrhea, screening for chlamydia.”… But a handful of students will say, I don’t want my parents to know. In that case, we do have some discount or what we call client pricing from our lab, which is quest labs. So, some of those students opt to pay out of pocket. And certainly It’s kind of rubs me the wrong way that these students are insured, but then they have to pay out of pocket just because of the insurance companies policy to send an explanation of benefits, to the parents, which may include information that the student may not want their parents to know.” – Low probability, high-prescribing provider (ID 13)
Facilitators of PrEP Prescribing
Provider education, background and experience facilitate PrEP prescribing	“I worked in [a low-income sexual health] clinic because I grew up very poor and I feel that the poor patients and patients with no insurance should be treated just as well as patients with insurance. And with much respect and dignity as other patients should be paid. And so, I felt like going into that clinic was the way for me to know offer those services and provide positive care for a lot of people who are at risk.” – Low probability, high-prescribing provider (ID 15)
Clinic structure and policies can support PrEP prescribing	“My program is committed to giving out PrEP. It’s a decision that we made as part – It’s a disease control program. So, we were committed to doing that. And we have not only a social worker doing all the paperwork and the support work. But when I go to the clinic to do PrEP, have someone drawing the bloods for me. And – which includes creatinine and – well, when they first start in my – include a hepatitis screen, liver function tests, creatinine etc. So not only is there a social worker helping, there’s lab supports. So, I’m in a program that’s truly committed. And if patients don’t show up for an appointment, someone calls, they get reminders.” – Low probability, high-prescribing provider (ID 10)
Characteristics of patient panels facilitate increased PrEP prescribing	“Well, I mean I think It’s easy in college health where we’re at -I mean the main focus that a lot of these kids have is about sex, and also - and risky behaviors. And so, we wouldn’t be doing our job in college health if we’re not addressing these issues. So I think It’s this nature of doing college health for the past 15 years, this is where I’m most comfortable, compared to like give me a patient with heart failure and I’ll be like, ‘Oh my god, I don’t know what to do.’” – Low probability, high-prescribing provider (ID 09)
Social Network Intervention Opinions and Recommendations
Desired Best Practice Information
PrEP standard of care information would help PrEP uptake	“One mistake we often make with any clinician we get is given to us in a non-evidence-based delivery method. So, the method that I would want it, not how people usually do it. I would want to know among patients – among gay males the risk of HIV is – for the standard person is one in 100, and should they take PrEP, the risk then would go down to one in 10,000.” – High probability, low-prescribing provider (ID 16)
Sharing prescribing rates among comparable providers could influence prescribing	“Yeah. Oh, absolutely, absolutely, because I as physicians, we always think we’re doing a lot better than the reports. Okay, maybe I need to really need to do better. So yeah, I think that It’s very insightful for us to get that information.” – Low probability, high-prescribing provider (ID 13)
Preferred Information Sources
Influential MDs and government agencies	“I think that if someone was still skeptical about the practice to begin with, they would want to hear from an infectious disease researcher and epidemiologist, who can say from the fact that they’ve read all the studies and that it is, that works.” – Low probability, high-prescribing provider (ID 04)
Providers already prescribing PrEP	“Yeah, so I would say I want to - I’m a PCP. I want to hear from another PCP just how straightforward this is and how they work it into all of the other things that on a plate.” – Low probability, high-prescribing provider (ID 04)
Information from pharmaceutical representatives is not desired	“Leading experts first, peers, second [as preferred information sources] and pharmaceutical companies. Yeah. The pharmaceutical companies they’re out there. But I think a lot of physicians especially myself, we have this general distrust of the pharmaceutical companies because we feel that their bottom line is a financial as opposed to a patient care. However, that’s certainly a jaded perspective on my side because I know the pharmaceutical companies do so much for our patients, whether It’s a patient assistance program, support, educational, opportunities for patients. So, they do a good job there. But I still would certainly go, put my trust in an unbiased expert in the field.” – Low probability, high-prescribing (ID13)
Preferred Delivery Mechanisms
The best information source is continuing medical education (CME) courses	“Particularly like when we get them for free, like the National STD Curriculum like when you do their CME stuff, you get free CME for that. They don’t have one though on PrEP. So free CME is like a huge motivator at least for me because it adds up.” – Low probability, high-prescribing provider (ID 11)
Receiving information through email is not desired	“I feel like we get inundated with emails, and I don’t send - if an email is not from somebody I know or, you know, I tend to not read them, I just delete them.” – Low probability, high-prescribing provider (ID 09)