Findings:
This national, survey-based study queried psychiatrists about their experiences with HIV Pre-exposure Prophylaxis (PrEP), and barriers to prescribing and management of PrEP. 19.3% of all respondents had received a request from patients for at least one PrEP prescription, and the majority of these reported a total of 1 to 5 requests. The majority of those receiving a request, responded by providing a prescription. 17.3% of psychiatrists had prescribed PrEP and most had prescribed 1 to 5 times. Compared to outpatient psychiatrists, those practicing in inpatient settings were more likely to prescribe PrEP. Psychiatrists with more confidence managing general medical conditions and PrEP-related tasks were also more likely to prescribe PrEP. Even though the large majority of psychiatrists had not been asked to, or had not prescribed PrEP, most psychiatrists were interested in prescribing. Interestingly, those who had completed a community psychiatry fellowship were less like to be interested in prescribing. The most commonly cited barrier to PrEP prescribing was lack of knowledge, followed by the need to manage follow-up care and PrEP lying outside scope-of-practice. Administrative requirements from insurers were the most common systems-level barrier, followed by time constraints and lack of a referral process to Infectious Diseases for those testing HIV-positive. The greatest percentage preferred a model of care in which the psychiatrist would provide the initial prescription with referral to primary care or Infectious Diseases for follow-up. A majority were also interested in receiving PrEP education, with online training being the preferred method. The group of psychiatrists who had prescribed PrEP, compared to those who had not prescribed after being asked, reported greater confidence managing general medical conditions and PrEP-related tasks. 

Strengths and limitations:
This study’s strengths included its large size, national scope, and its use of multiple recruitment methods, including the use of the American Medical Association Physician MasterFile, a large, national listserv of psychiatrists, for distribution of the survey and multiple reminders. The distribution method oversampled those jurisdictions with the highest HIV incidence, identified by the federal program – Ending the HIV Epidemic. Additionally, information about the study was distributed at the 2023 American Psychiatric Association Annual meeting. The survey instrument was based on previously published studies of primary care and infectious disease physicians’ perspectives on PrEP implementation, and was refined by experts in psychiatry and infectious diseases. Study findings may not be generalizable to all practice settings, including community settings and geographic regions, since the majority of respondents were affiliated with academic medical centers in large, urban areas. Also, the study did not include non-physician and non-psychiatrist providers, such as physician assistants and nurse practitioners who may comprise primary points-of-contact for people with mental illness, especially in rural areas. The survey’s low response rate, although similar to prior studies of physicians’ experience with HIV PrEP, may also limit generalizability of findings.      

Relevance:
This study is the first of its kind to examine psychiatrists’ experience prescribing PrEP, to explore barriers to implementation of the CDC, Grade A recommendation for PrEP provision, and to recommend provider- and systems-level approaches to increasing PrEP uptake among people with mental illness. The study’s relevance is underscored by the disproportionately high HIV incidence among people with mental illness and substance use and inadequate PrEP uptake among these and other vulnerable populations. Recent studies have shown scarce availability of HIV testing in mental health outpatient settings, and PrEP services in outpatient substance use facilities, even when co-located HIV treatment services were present. Study findings suggest opportunities for the development of models of care to meet these unmet needs of our patients. For example, injectable cabotegravir administered every other month could be easily integrated into outpatient psychiatric and substance use treatment settings that have the capacity to administer long-acting injectable psychotropic and anti-craving medications. “Reverse integration” models could also be adapted to include PrEP services. This study demonstrates that with appropriate training and infrastructure support, many psychiatrists would consider providing HIV PrEP to their patients.