Physicians who are reluctant or even opposed to broad use of pre-exposure prophylaxis (PrEP) against HIV may keep physician assistants and nurse practitioners from prescribing the antivirals that can prevent infection and spread of HIV. Making PrEP an over-the-counter treatment would be one way of increasing access.

Many studies have shown that pre-exposure prophylaxis (PrEP) is an effective strategy for preventing HIV infections, especially because there is no vaccine against virus. But nurse practitioners and physician assistants may not be able to prescribe PrEP depending on which state they practice in, blunting the effective of policies and programs promoting PrEP, according to a study conducted by the Division of HIV Prevention at the CDC .

The CDC study examined if there was a correlation between state-level scope of practice laws and prescriptions for PrEP. “Each state has scope-of-practice laws that specify the degree of autonomy that nurse practitioners and physicians have when diagnosing conditions and prescribing controlled medications,” says Neal Carnes, Ph.D., a behavioral scientist with the CDC.

Carnes and colleagues analyzed nationwide data on more than 79,000 people who received their PrEP prescription in 2017. Physician assistants in states where the law or a state board gives them the ability to prescribe PrEP were 2.6 times more likely to prescribe PrEP than physician assistants in states that required oversight by a medical doctor. Similarly, nurse practitioners in states that allowed independent scope of practice were 1.4 times more likely to have prescribed PrEP compared with nurse practitioners in states where with limited scope-of-practice laws. These and other results from the study were published in the Journal of the Association of Nurses in AIDS Care.

“Previous research found that some medical doctors were not willing to prescribe PrEP or had reservations about prescribing PrEP to certain or all indicated populations,” Carnes says. “The findings from CDC’s study suggest people with indications for PrEP may confront an access barrier if they live in a state that restricts scope of practice and are in the care of nurse practitioners and physician assistants being supervised by medical doctors not knowledgeable about, who hold a contrary attitude toward, or are unwilling to prescribe PrEP.”

Carnes say physicians in limited scope-of-practices state could hamper PrEP access through nurse practitioners and physician assistants if they believe that PrEP should be limited, say, to people in monogamous relationship or those who engage in heterosexual sex.

The availability of supervising medical doctors is another barrier that can result from restrictions on scope of practice.

“The supervising medical provider may require a consultation with the patient before a new course of treatment is prescribed,” Carnes says. “However, that same medical doctor might have limited availability in their schedule for that consultation. In these cases, the nurse practitioner or physician assistant may default to other prevention methods like condoms.”

The study notes that addressing prescribing and practice restrictions may help increase access to PrEP among patients served by nurse practitioners and physician assistants. Additionally, increasing awareness and understanding of PrEP among medical doctors, nurse practitioners, and physician assistants can assist in minimizing the influence that scope of practice laws may have on PrEP access.

“To increase knowledge of PrEP’s efficacy and address concerns held by hesitant providers, states could consider expanding PrEP detailing and education efforts that focus on medical doctors, as well as the nurse practitioners and physician assistants they supervise,” Carnes says. “Also, expanding over-the-counter PrEP would mitigate scope of practice oversight as an access barrier.”

Carnes also sees a role for detailing — marketing of PrEP to doctors b sales representatives for drug makers.

“Detailing provides an opportunity to help providers understand how to integrate PrEP prescribing and on-going clinical care into their routine practice,” Carnes says. “Most notably, PrEP detailing can assist the provider in understanding the importance of taking a detailed sexual history and getting comfortable asking these questions when it might not have been part of their medical training or practice previously.”