Topical Microbicides for HIV Prevention Available for Youths, But Barriers Remain
By Carole Ellis
Physicians call for more education for themselves and the patient before recommending the use of topical microbicides.
Although most physicians report that they are "comfortable with recommending and prescribing a topical microbicide to youths" to assist in preventing the spread of HIV, they also indicated that there are a few key barriers to using this method of prevention.
According to Tanya Mullins, MD, MS, a physician at the Cincinnati Children's Hospital Medical Center, who presented her research team's findings at the 2017 Pediatric Academic Societies Meeting (PASM), physicians would be more likely to prescribe topical microbicides if they were covered by insurance, came with better patient education, and were available without a prescription. "Although many physicians voiced comfort with recommending and prescribing [topical microbicides], physician educational materials and clinical guidelines should be developed," Dr. Mullins said.
In 2010, the Centers for Disease Control and Prevention (CDC) reported that nonspecific topical microbicides were "ineffective" and "should not be recommended for STDs/HIV prevention" by physicians. Since then, the CDC has not revised this announcement, although, in 2015, the CDC's Clinical Prevention Guidance noted that several "topical antiretroviral agents exist for the prevention of HIV" and are currently under evaluation. Dr. Mullins and her team believe that "biomedical HIV prevention methods, such as topical microbicides, have the potential to significantly reduce new HIV infections." The methods she specifically highlights are a tenofovir vaginal gel, and dapivirine administered through a vaginal ring. "Because microbicides are likely to require a prescription by a healthcare provider when they become available, and [because] youth are likely to seek such services from their primary care providers, [we chose to interview these providers to learn their thoughts because] these results could determine preconceived barriers to prescription," the team noted.
Dr. Mullins and her team conducted a series of audio-recorded, semi-structured, face-to-face interviews with 38 physicians in an unspecified "large midwestern city." Eight of the interviewees practice general pediatrics, eight are in obstetrics/gynecology, eight practice family medicine, six work in internal medicine, and eight practice adolescent medicine. Of these physicians, 27 were female, and the group had a mean of 19 years' experience since graduating from medical school. Overall, the group had a total of 9 HIV-infected youth currently in their practices, and 7 had an existing familiarity with microbicides.
The physicians identified "numerous benefits of prescribing microbicides to adolescents," Dr. Mullins said. Those benefits included: decreased acquisition of HIV, improved provision of sexual health services, improved patient awareness of risk behaviors, better adherence to prophylactic measures, patient empowerment to control their own sexual health, and non-partner-reliant prevention. However, they also noted a number of barriers to prescribing such agents, including: lack of acceptability to patients (66%), concerns about ease of use (24%), and lack of patient knowledge and perceived personal risk of HIV (21%). The physicians also identified several physician-level barriers to prescription, including: parental barriers (45%), adherence concerns (53%), safety and side effects issues (42%) and lack of provider education (24%). About a fifth (18%) also said that they would be concerned that such topical treatments might lead to riskier sexual behaviors, and 89% said that the treatments would cost too much and would likely not be covered by insurance.
In addition to these general concerns, several physicians identified specific needs that they felt would simplify the process of prescribing topical microbicides. "As far as gels and things like that, I would want some... teaching device to show somebody how to put it wherever they need to put it," said one study participant, while another recommended simply putting these microbicides "right next to the condoms, and don't lock [them] up" to make the treatment both accessible and easy for patients to get without a prescription.
"Patient educational strategies, physician educational materials, and clinical guidelines recommending the use of microbicides should be developed [to optimize prescription]," Dr. Mullins concluded.