LAUSR

To the Editor: Newman R, Katchi T, Karass M, et al. Enhancing HIV Pre-exposure Prophylaxis Practices via an Educational Intervention. Amer J Ther 2019; 26:e462–e468. HIV pre-exposure prophylaxis (PrEP) has demonstrated meaningful efficacy in high-incidence populations.1,2 In 2015, only 10% of PrEP candidates were on therapy, and approximately 1/3 of primary care physicians (PCPs) had ever heard of PrEP.3,4 Clinicians reporting knowledge gaps have been less likely to offer PrEP, thus enhanced education in this area holds promise.5 Resident physicians represent a large, impressionable audience with few studies providing insight into how they perceive, utilize, or learn about PrEP.6,7 Thus, we enjoyed reading the report in this journal by Newman et al describing a PrEP educational intervention project within their internal medicine (IM) residency. Similar to their initiative, we distributed an optional, anonymous, online questionnaire (SurveyMonkey, Inc, Palo Alto, CA; www.surveymonkey.com) to determine IM residents’ initial understanding and use of HIV PrEP as a 11-item “baseline survey,” followed by a 1-hour lecture (“intervention”) delivered by a study author (J.P.H.), concluding with a postintervention assessment (“follow-up survey”). The Fisher exact test was used for statistical analyses of preintervention/postintervention effects. A total of 97 baseline surveys were distributed to our entire IM residency; 41 (42.3%) were completed. We were particularly interested in residents’ awareness of PrEP and how frequently and comfortably they were using it clinically. Other questions queried key learning points (eg, efficacy and drug regimen). Most respondents endorsed PrEP awareness (n 5 28, 68%), similar to the 78% rate reported by Newman et al. Few had prescribed PrEP or referred a prospective patient to an infectious disease (ID) specialist in the preceding year (n 5 6, 14.6%), approximating the 18% rate seen by Newman et al. Within the baseline-aware group (n 5 28, 68%), there was a trend toward comfort with using PrEP (21 vs. 6; 75.0% vs. 46.2%, P 5 0.09). Notably, all prescriptions/referrals were among the baseline-aware group (6 prescriptions/referrals vs. 0; 21.4% vs. 0.0%, P 5 0.08). The postintervention survey was sent to the same group with 15 (15.5%) returned. After intervention, more residents correctly identified the medication regimen (9/9 vs. 20/41, 100% vs. 48. 7%, P 5 0.007), but improved clinical comfort did not attain statistical significance (8/9 vs. 27/41, 88. 9% vs. 65.8%, P 5 0.25). Many respondents indicated sustained preference to refer patients to an ID/HIV specialist (6/15, 42.9%). Only one respondent cited persistent concerns with safety or risk-behavior compensation (6.67%). Aside from ID specialists, PCPs are likely to encounter many patients who might benefit from PrEP, particularly in low-resource settings. The Southern region carries the highest burden of new HIV diagnoses in the United States, yet regional PrEP uptake has consistently lagged behind other areas.8,9 As important care providers in many low-resource settings, IM residency programs should explore opportunities to educate their residents about PrEP, especially those in highincidence locations. Awareness may improve clinical uptake of PrEP among trainees, but our results suggest that educational interventions may be only partially effective. Regardless, PCPs may prefer ID/HIV specialists to manage PrEP patients—a phenomenon that likely warrants clarification. Ultimately, additional data are needed to define optimal PrEP curricula for medical residents.