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PrEP "Purview Paradox" Leaves Providers Uncertain

Since the US Food and Drug Administration approved the use of pre-exposure prophylaxis (PrEP) for HIV prevention in 2012, use has been plagued by a “purview paradox.”

Due to conflicting beliefs concerning which personnel in which settings should prescribe PrEP, there is no consensus on which clinicians are in the optimal position to implement PrEP care in health care systems. Neither infectious disease (ID) specialists nor primary care providers (PCP) appear to consider PrEP care to fall within their practice, and similar debates have taken place between nurses and physicians.

An oral abstract presented at the Association of Nurses in AIDS Care Conference (ANAC 2019) examined the purview paradox in order to assess which providers were more likely to prescribe PrEP in the US.

Abstract authors conducted a comprehensive literature search to identify peer-reviewed articles about the role of different health providers in PrEP care implementation. They found 11 studies addressing PrEP care implementation with respect to ID specialists and PCPs, as well as 18 studies describing the position of nurses in PrEP care. Abstract authors conducted random effects model meta-analyses on the data.

Out of all health professionals included in the analyses, 34% were ID specialists, including HIV specialists, and 27% were nursing personnel. ID specialists had higher odds than PCPs of prescribing (odds ratio [OR]=4.06, 95% confidence interval [CI]=3.12, 5.28), being aware of (OR=6.11, 95% CI=3.56, 10.48), and willing to prescribe PrEP (OR=3.06, 95% CI=2.27, 4.11).

Analyses also indicated that the odds of PrEP prescription were 1.51 (95% CI=1.09, 2.09) times higher among nurses.

Findings revealed that ID specialists were more likely to prescribe PrEP than PCPs, and that nurses were more likely to prescribe PrEP than physicians. Abstract authors recommended that “targeted programs for PrEP implementation should be provided for these neglected but key groups in the health care settings in order to scale up PrEP care in the [United States].” ‘

The abstract, Understanding “Purview Paradox” in the Implementation of Pre-Exposure Prophylaxis Care in the United States, was presented in an oral abstract session at ANAC 2019 in Portland, Oregon. 
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