A cross-sectional survey of general practitioner knowledge, attitudes, and clinical experience of HIV PrEP

Norway’s capital of Oslo is the nation’s most populated city (Høydahl 2020), where HIV incidence remains highest (Blystad et al. 2019), and is host location for the evaluation of PrEP implementation project (Hanlon et al. 2019). Consequently, Oslo could be considered the PrEP epicenter of Norway, and was the rationale for restricting our study population inclusion criteria to currently practicing GPs in Oslo. At the end of 2018, there were an estimated 527 practicing GPs in Oslo (Gaardsrud 2019). To calculate our target sample size in STATA (StataCorp 2017), we referred to a previous study of PrEP implementation among Belgian physicians (Reyniers et al. 2018) to base our assumptions of proportion/prevalence of GP PrEP adoption, and its association with PrEP knowledge and attitudes. A sample size of 112 Oslo GPs was required to achieve 80% power (at 5% significance level), while a sample of 148 Oslo GPs would achieve 90% power. A total of 117/527 Oslo GPs responded to our survey, resulting in a 22% response rate.

Study invitations and surveys were distributed using a sequential web-mail recruitment method. The web survey invitation and subsequent reminders were first emailed to the head physician of each subdivision within Oslo, who then forwarded the survey to their respective GP listservs. The first web survey invite took place in November 2019, followed by two email reminders with a web survey link at 3-week intervals. Postal survey distribution took place in late January 2020 and contained, per GP within each clinic: one survey invitation letter, one survey, and one pre-stamped return envelope. Web and mail data collection closed in February 2020. Between the two survey modes, 44 respondents submitted responses to the web survey, while 73 respondents completed and returned the postal survey.

Personal GP characteristics included demographic variables (gender identity, sexual orientation, country of birth), as well as details regarding clinical experience (location of medical exam, years of experience, number of GP colleagues in current practice setting). Respondents were provided the option of ‘prefer to not answer’ to survey items that could be perceived as too sensitive. Patient demographics were also captured by asking respondents to estimate the approximate number of LGBT patients (0, < 5, 5–10, 10+, do not know), and proportion of patients belonging to an ethnic minority background (< 25%, 25–50%, 50%+, do not know) currently on their list.

One caveat to a GP referring eligible patients to a PrEP clinic is having completed a recent sexual history and STI screening. Survey items regarding GP self-reported comfort providing PrEP-related activities to patients of various demographics were measured using a five-point Likert scale; with the most negative response options (very uncomfortable, very difficult) coded as ‘1’, ascending to the most positive response options (very comfortable, very easy) coded as ‘5’. Five-point Likert scales were also used to measure the nine GP self-reported PrEP attitudes (strongly disagree to strongly agree). Selected Likert-scale survey items were combined to create unique composite scales that would act as continuous exposure measures in the data analysis. This resulted in four composite scales: GP comfort in discussing sex with LGBT identifying patients (four items, Cronbach’s α = 0.81); GP comfort in discussing sex with patients from ethnic minority backgrounds (three items, Cronbach’s α = 0.77); GP accepting attitudes towards PrEP (five items, Cronbach’s α = 0.74); and GP concerned attitudes towards PrEP (four items, Cronbach’s α = 0.67). Accepting PrEP attitudes included statements such as: ‘PrEP should remain free of cost’ and ‘It is reasonable to schedule control consultations every 3 months to healthy patients’. Concerned PrEP attitudes included ‘PrEP could lead to an increase in patient HIV risk behaviours’ and ‘PrEP isn’t necessary — condoms are already an effective HIV prevention strategy’.

In addition to the four composite exposure scales, two independent exposure variables were included in the multivariate analysis. GP self-reported PrEP knowledge was measured by one survey item with a six-point Likert scale (never heard of PrEP to excellent PrEP knowledge level) and treated as a continuous variable. As a proxy exposure to measure a GP's frequency of carrying out PrEP-related activities, we used the one categorical survey item capturing the number of syphilis tests provided by a GP in the last 3-month period (0, < 5, 5–10, 10+).

The outcome variable of interest was GP PrEP adoption (Krakower and Mayer 2016; Turner et al. 2018). Survey respondents were asked if they had ever provided a patient with a referral or prescription for HIV PrEP. Respondents who answered ‘yes’ were classified as PrEP-adopters, while those who answered ‘no’ were classified as PrEP non-adopters.

Descriptive analyses of the survey GP respondents (Table 1) demonstrates that 80% (93/117) identified as heterosexual, 85% (99/117) were born in Norway, and 71% (83/117) completed their medical training exam in Norway. About half (49.6%) of respondents either claimed to not know or not have any transgender-identifying patients on their list. Twelve (10.3%) of the respondents indicated either not knowing or having any LGB-identifying patients on their list. Most respondents answered having ≤ 25% patients from ethnic minority backgrounds on their list. Just over half (60/117) of respondents were classified as PrEP adopters, and the remaining 49% (57/117) were classified as PrEP non-adopters.

Univariate analysis of GP and patient demographics in association with GP PrEP adoption demonstrated significant findings when it came to GPs who identified as men (OR 2.1; 95% CI: 1.0–4.5) and as LGB (OR 4.4; 95% CI: 1.4–14.5). GPs who had ten or more LGB patients on their list were more likely to be PrEP adopters (OR 4.4; 95% CI:1.8–10.4) (Table 1). Multivariate analysis of the main exposure composite scales (frequency of PrEP-related activities, comfort discussing sex with LGBT and ethnic minority background patients, self-reported PrEP knowledge, accepting and concerned attitudes towards PrEP) are presented in Table 2.

The number of syphilis tests provided by a GP in the last 3 months showed no association to GP PrEP adoption. Moreover, despite a majority of respondents indicating high comfort and ease discussing sex with patients, no significant association with PrEP adoption was observed (data not shown).

Proportion frequencies for GPs’ self-reported knowledge level of PrEP by adoption status (PrEP adopters vs PrEP non-adopters) are illustrated in Fig. 1. A GP’s PrEP adoption status was significantly (p < 0.01) associated with level of self-reported PrEP knowledge (OR 2.4; 95% CI: 1.3–4.4). For every one-unit increase in PrEP knowledge level (six-point Likert scale), there was an increase of 0.88 (95% CI: 0.29–1.47) in the likelihood of a GP being a PrEP adopter.

Frequencies (%) of GP responses to the nine survey attitude statements can be seen in Fig. 3. In the multivariate analysis, neither one of the PrEP attitude scales (accepting, concerned) were found to be associated with PrEP adoption (Table 2).

This is the first study to our knowledge of any Nordic country to explore GP knowledge, attitudes, and clinical experience of HIV PrEP. We found that GP PrEP adopters were more likely to identify as men, LGB, and have ten or more LGB patients on their list. Our main finding with regard to the positive and significant association between GP PrEP knowledge and PrEP adoption appears to be consistent with previous studies (Krakower and Mayer 2016; Turner et al. 2018; Zablotska and O'Connor 2017).

Norway has made commendable advances in HIV prevention and treatment efforts, having recently surpassed the UNAIDS’ 90–90–90 treatment targets (Whittaker et al. 2020), and estimated to have a minimal PrEP gap (Hayes et al. 2019). Still, such accolades are threatened by the noted association of low HCP PrEP knowledge negatively influencing PrEP adoption in general (Nunn et al. 2017; Petroll et al. 2017; St. Vil et al. St.Vil et al. 2019), as well as the lengthy PrEP specialist wait times documented in Oslo (Hanlon et al. 2019). As PrEP gatekeepers, GPs are integral to patient access to PrEP. GPs lacking PrEP awareness and knowledge run the risk of missing eligible PrEP candidates, therefore increasing Norway’s PrEP Gap. The current regulatory division of labour between medical professions regarding PrEP prescribing privileges and provision of the associated ongoing care may already be fueling this gap in Norway (Simonsen 2020). Globally, many health systems with such a division in PrEP care delivery have observed a phenomenon known as the purview paradox; which refers to the lack of consensus among medical professions surrounding which among them should be responsible for the prescribing of PrEP and/or for the ongoing monitoring of PrEP users (Krakower et al. 2014). Infectious disease specialists have the expertise  to identify eligible PrEP candidates and carry-out the required ongoing care; however, they are also more likely to already follow patients living with HIV. In contrast, GPs are more likely to see HIV-negative patients and are therefore better situated to initiate the PrEP care cascade, but often hold concerned attitudes and low knowledge of PrEP (Zablotska and O'Connor 2017). Nevertheless, there appears to be a need to better equip PrEP gatekeepers with the required knowledge, skills, and confidence to effectively identify and engage eligible PrEP users. Otherwise, there is the risk that patients may turn to obtaining PrEP through unconventional means. For example, a trend of informal PrEP use outside of healthcare settings has been observed within European and Central Asian countries (ECDC 2019). Findings from the 2017 European-Men-Who-Have-Sex-With-Men Internet Survey (EMIS) (Weatherburn et al. 2019) indicated that informal PrEP users primarily accessed PrEP by purchasing online and/or borrowing from a friend (ECDC 2019). Most concerning, one-third of EMIS-2017 respondents accessing informal PrEP stated they had not disclosed their PrEP use to their healthcare provider(s) (ECDC 2019). Informally-accessed and/or unmonitored PrEP use can lead to negative outcomes for the individual, and as a result potentially burden healthcare systems by way of: the development and transmission of drug-resistant strains of HIV; compromised renal functioning; and complications due to undiagnosed/untreated STIs.

As PrEP formulations and guidelines continue to evolve, a collaborative and multi-sectoral effort is essential to adapt region-specific PrEP indications and training relayed to PrEP gatekeepers (Krakower and Mayer 2016; Sullivan and Siegler 2018; Zablotska and O'Connor 2017). Two unique models have been proposed to identify facilitators of accelerated PrEP implementation (Krakower and Mayer 2016; Zablotska and O'Connor 2017). Interestingly, both models advocate for peer-based education among HCPs. It is argued that peer education would be cost-effective and not only enhance knowledge of PrEP, but also build HCP skills in sexual-history taking, assessing risk behaviours, and overall competence of sexual minorities (Zablotska and O'Connor 2017).

When GPs in our study survey were asked what they would need to have more informed conversations about PrEP with patients, we found that 74% (42/57) of PrEP adopters and 89% (50/56) of PrEP non-adopters indicated they would need access to Norwegian PrEP guidelines (Fig. 2). We found it particularly intriguing that among PrEP adopters in our study, 53% (30/57) expressed a desire to build on PrEP adoption capacities in the form of an e-learning course, and 25% (14/57) via the in-person opportunity to shadow a PrEP-experienced GP. This would suggest that PrEP adopters are aware of the necessity to maintain their self-reported high-level PrEP knowledge, as it is crucial to stay informed of pertinent evidence-based findings and guideline revisions. On the other hand, this may also signal that PrEP non-adopters could benefit even more from such training and education, given the lack of PrEP implementation in their practice. Among PrEP non-adopters, 38% (21/56) indicated a preference for an e-learning course on sexual history taking/sexual health in general, and 34% (19/56) would need an e-learning course on PrEP.

While our findings with regard to GP PrEP attitudes and PrEP adoption differed from the literature (Krakower and Mayer 2016; Turner et al. 2018; Zablotska and O'Connor 2017), they still merit some reflection. A commonly cited HCP PrEP concern has been risk compensation (Blumenthal and Haubrich 2014; Desai et al. 2017; Powell et al. 2019); essentially, the fear of increased HIV risk-taking behaviours among PrEP users, which will in turn burden healthcare systems via compromised drug efficacy, increased STI incidence, and antiretroviral therapy (ARV) resistance. We observed a large proportion of respondents indicating that they ‘did not know’ their level of agreement for many of the attitude statements (Fig. 3). A possible explanation for this finding may be attributed to the potential ambiguity of the attitude statements. For example, 48% (56/116) of respondents agreed or strongly agreed that "HIV PrEP could lead to an increase in STIs", which could be interpreted as a consequence of risk compensation. Alternatively, this same statement could be perceived as an acknowledgement that due to the amount of routine STI testing involved with PrEP care, more STIs are likely to be diagnosed earlier and treated. Consequently, our findings on any association between accepting and concerned GP attitudes on the PrEP adoption outcome were unclear. 

According to one methodological review on HCP response rates to PrEP surveys, our 22% response rate (117/527) can be considered fair (Silverman et al. 2018), albeit a limitation to the study. However, the challenge to obtain an acceptable HCP survey response rate has been well-documented (Cho et al. 2013; Kellerman and Herold 2001; Pit et al. 2014). At the same time, we are not able to rule out the presence of selection and non-response biases. There is a chance that only GPs interested and comfortable with topics related to sexual health participated in the survey, and/or did not answer truthfully to appear more comfortable and accepting of PrEP and related activities. Moreover, in the context of PrEP and HCP research, it has been argued that “not capturing a lack of adoption could result in an overestimation of the amount of providers offering PrEP and an underestimation of the need for PrEP-related medical training and dissemination efforts” (Silverman et al. 2018). However, it should be noted that the evaluation of non-response bias differs between physicians and the general public (Kellerman and Herold 2001). Physicians can be considered a homogenous group given their shared training, knowledge, attitudes, and behaviour; and therefore pose less of a concern of non-response bias compared to surveys of the general public (Kellerman and Herold 2001). Lastly, the interpretation of GP PrEP-related activity frequency was difficult to decipher based on the variation between ORs and AORs. This could suggest that the number of syphilis tests provided in the past 3 months was a poor proxy for frequency of PrEP-related activities.

Ensuring PrEP guidelines are streamlined and more readily accessible to GPs would be one approach to fostering GP knowledge and confidence to refer eligible patients for PrEP. Hence, consolidating existing sexual healthcare service provision guidelines to include the indications and care for PrEP, and making said guidelines easily accessible, is one suggested manner in which our research findings can be translated and implemented into general practice. Further, the opportunity to shadow GPs familiar with PrEP in clinical settings provides one avenue of peer-education which might be suitable in certain settings wherein GPs have both time and resources for such educational training. While this recommendation has been highlighted in the current literature (Krakower and Mayer 2016; Zablotska and O'Connor 2017), it should be noted that such training presupposes building infrastructure and capacities so that GPs who may want training can both gain access and have the time to participate. Moreover, this would also entail that a network of PrEP adopters would be available to provide such training in a formalized manner. As such, this form of peer-based education might require extensive resources and therefore may not be suitable for all settings. Consequently, online peer-based training may be more feasible to coordinate, via webinars or digital pre-recorded educational materials. Lastly, given the literature linking high HCP PrEP knowledge with high knowledge of and comfort with PrEP-related activities, (Nunn et al. 2017; Petroll et al. 2017; St. Vil et al. St.Vil et al. 2019), further research may be warranted to investigate if our findings are echoing a gap within sexual healthcare service provision in general.