Half of all new HIV infections [1] occur in the Southeast United States (U.S.). HIV surveillance data show that the majority of HIV diagnoses in this region are among African Americans [2]. Compared with whites, African Americans in the Southeast experience higher rates of undiagnosed HIV infection [3] and are more frequently diagnosed with Stage 3 (AIDS) infection [1]. Various factors including social and structural inequities contribute to these disparities [4, 5]. Furthermore, these circumstances also correlate with individual-level behaviors such as infrequent HIV testing [6] and lower uptake of biomedical prevention tools [7] that further exacerbate negative HIV prevention and care outcomes.

Primary care providers (PCPs), which include physicians, nurse practitioners and physician assistants, serve important public health roles in HIV prevention and care [8, 9]. These frontline providers are uniquely positioned to inform, educate, and deliver HIV-related prevention services to all persons. Optimal prevention services are particularly important for African Americans living in the Southeast, who are disproportionately affected by HIV [10]. As a resource, the Centers for Disease Control and Prevention (CDC) has published clinical guidelines for PCPs to provide HIV prevention services, including screening [11]. These services also include biomedical prevention tools, specifically pre-exposure prophylaxis (PrEP) and non-occupational post-exposure prophylaxis (nPEP), for sexual exposure [11, 12]. However, recent evidence indicates that primary care providers may not be comfortable or sufficiently skilled to provide such prevention services [13]. Furthermore, PCPs lacking appropriate HIV-related training may directly or indirectly deter patients from seeking biomedical prevention tools such as PrEP [13–15]. Efforts to increase provider knowledge have been linked to higher prescription rates of PrEP [16, 17] and nPEP [18] among PCPs. However, few studies have examined the overall readiness of PCPs to provide these services and the impact of HIV-related training on their ability to do so. Assessing the preparedness of PCPs to provide prevention services is particularly salient for reducing HIV incidence and disparities in high HIV-burden locations of the Southeast.

To address this gap, we examined the provider characteristics and practices associated with HIV-related training experience among a representative sample of PCPs practicing in six metropolitan statistical areas (MSAs) with high HIV burden among African Americans located in the Southeast. Our specific objectives included (1) assessing the levels of prior HIV-related training and (2) investigating whether and how self-reported HIV-related training correlates with provider characteristics, HIV screening practices, knowledge about HIV biomedical interventions, and prescribing of biomedical interventions.

Baseline survey fielding Efforts yielded a sample of 820 participants enrolled into study. Based on weighted frequency distribution, provider characteristics included the following: 49.7% ≥ 50 years of age, 59.4% female, and 60.2% white. In addition, our weighted sample comprised 75.6% physicians, 20.7% nurse practitioners and 3.6% physician assistants. Almost half (47.6%) of the sample practiced in the Washington, DC and Baltimore, Maryland MSAs. In addition, 36.3% of PCPs self-reported HIV-related training (Table 1).

In bivariate analyses, we found that PCPs with HIV-related training were more likely to practice in Miami (PR = 1.85, 95% CI 1.52, 2.25) versus Atlanta, offer HIV screening annually or more often (PR = 1.54, 95% CI 1.25, 1.92), and provide condoms to patients at their practice facility (PR = 1.79, 95% CI 1.20, 2.63). The bivariate model also indicated that PCPs with HIV-related training were more likely to be more familiar with nPEP (PR = 2.08, 95% CI 1.67, 2.56), ever have a patient request nPEP (PR = 1.52, 95% CI 1.20, 1.92), and more likely to ever prescribe nPEP to at least one person (see Table 2). In addition, the bivariate model indicated that PCPs with HIV-related training were more likely to be familiar with PrEP (PR = 2.63, 95% CI 2.13, 3.23), ever have a patient request PrEP (PR = 1.49, 95% CI 1.22, 1.82), and ever prescribe PrEP (PR = 2.00, 95% CI 1.59, 2.56).

In the multivariable analysis [adjusted prevalence ratio (aPR), p ≤ 0.05] (Table 2), we found that PCPs who reported HIV-related training were more likely to practice in Miami versus Atlanta (aPR = 1.53, 95% CI 1.31, 1.78), provide condoms to patients at their practice facility (aPR = 1.52, 95% CI 1.03, 2.27), and be familiar with nPEP (aPR = 1.32, 95% CI 1.05, 1.67). In addition, PCPs with HIV-related training were more likely to be familiar with PrEP (aPR = 1.67, 95% CI 1.19, 2.38), ever prescribe PrEP to patients (aPR = 1.75, 95% CI 1.10, 2.78) and have patients requesting PrEP (aPR = 1.47 (95% CI, 1.12, 1.89).

We found that only one-third of PCPs in the selected Southeast locations reported any HIV-related training; the region is clearly in need of a better-prepared HIV workforce. Our results are consistent with other scientific reports showing insufficient provider competency to address the community’s HIV-related service needs [24, 25]. Although not examined in our study, PCPs’ lack of familiarity with HIV prevention tools could potentially serve as a barrier for client uptake of screening and prevention interventions [16, 26, 27]. Work-force shortages projected for available PCPs with HIV training [28] highlight the urgency of the issue.

Overall, we found that PCPs with HIV-related training were more likely to provide HIV prevention tools to their patients. Not surprisingly, increased HIV knowledge obtained via HIV-related training was associated with providing condoms and prescribing PrEP to patients. Other studies also found similar results: PCPs with increased PrEP knowledge were more likely to prescribe or offer patient referrals for PrEP [13, 29]. Other supporting evidence in the literature indicates that lack of knowledge may serve as a barrier to prescribing PrEP [17]. The positive correlation between provider training and delivery of prevention services reported in our study and others is encouraging.

Our analyses also revealed that PCPs with HIV-related training were more likely to report patients requesting PrEP; this finding aligns with reports from similar research studies [30, 31]. For instance, adequately trained providers may help create less stigmatizing clinical environments and enhance patients’ comfort with requesting PrEP [32]. In another study, African American women were less likely to seek HIV care if they perceived stigmatizing behavior from their health care provider [33]. Also, higher quality of HIV care was associated with obtaining care from PCPs with higher cultural competence [34]. Therefore, our study findings are consistent with previous studies that support the importance of HIV-related training to improve critical skills (i.e., cultural competency) among PCPs to increase uptake of prevention tools such as PrEP. Furthermore, uptake of such trainings can improve racial disparities in HIV prevention and care particularly in high HIV burden areas [35].

In our study, fewer than half of PCPs reported a “good” understanding of nPEP; these results were unexpected. Unlike PrEP, PEP use for HIV prevention has existed since 1996 for occupational exposure [36]; guidelines for nPEP have been available since 2005 [37]. Frontline healthcare workers have been a key target audience for PEP use to ensure occupational safety and transmission prevention [31, 38]. Given the longstanding availability of PEP (for occupational exposure), we expected greater familiarity with nPEP (for sexual exposure), particularly among PCPs in the Southeast. One possible explanation is that much of nPEP use involves medical emergencies related to sexual assault [18]. A recent CDC publication also elucidates that nPEP use should be reserved primarily for emergency situations [39]. Consequently, our findings may simply reflect these factors, which contribute to emergency department providers being more familiar with nPEP than PCPs. However, prevention strategies must include increasing nPEP familiarity among PCPs to improve public awareness and uptake of this HIV prevention tool.

Similar to our findings involving PrEP, HIV-related training among PCPs was associated with familiarity with nPEP. Other reports in the literature provide context for our findings. Institutional barriers to PCPs familiarity with nPEP include the lack of a written nPEP protocol [40] and the absence of appropriate staff training [18]. Unlike for the PrEP analyses, we did not find a correlation between HIV-related training and nPEP prescriptions. Of note, we found a trend toward an association between HIV-related training and PCPs reporting a high number of nPEP prescriptions (> 20 patients) in the multivariable model (p = 0.062), which appears in line with association between provider training and nPEP prescribing found in another study [31]. In aggregate, results from our study and existing literature suggest that low levels of familiarity and comfort with nPEP among PCPs in the Southeast are potential barriers to nPEP uptake among at-risk patients; further research is needed to explore these barriers.

We also found no statistically significant association between HIV-related training and HIV screening behaviors, in contrast to some prior studies that revealed these associations [41–43]. These results might be explained by unique facility characteristics and other unmeasured factors in our study, such as: lack of facility resources [44], lack of clinic protocols [45], and provider discomfort with discussing sexual history [45, 46]. While we did not collect data on these factors, they have been identified as correlates of low HIV screening. HIV-related training may influence screening behaviors, but perhaps also be mediated through jurisdiction- and facility-level factors rather than only provider-level factors. Further investigation is warranted.

Our study highlights the gaps in current HIV-related training needs and preparedness for frontline primary care providers. We found that capacity and training needs are most needed for improving general understanding and provision of PrEP and nPEP. Future research (e.g., qualitative studies) and program implementation science should examine facilitators and barriers associated with HIV-related training uptake. These investigations should also explore the learning modalities (e.g., online continuing education courses, academic detailing) that are acceptable, accessible, and beneficial to PCPs in the Southeast and could best enhance providers’ readiness to provide HIV care and prevention services in primary care settings. Lastly, future Efforts need to examine facility- and jurisdiction-level factors to design appropriate, culturally competent, and consistent trainings for PCPs to advance national HIV prevention and care goals for the Southeast.