Response from Author to: Letter to the Editor (re: DOI: 10.1089/apc.2023.0244)

To the Editor:

Here, we respond to Gieseken's and Ibañez's critique of the article, “Implementation Facilitators and Barriers for Primary Care Providers Prescribing Daily Oral PrEP to Adolescents in the United States.”

Gieseken and Ibañez critiqued that our article ¹ did not mention the role adolescent development has in adolescents' sexual behaviors and pre-exposure prophylaxis (PrEP) attitudes, nor the implications that primary care providers (PCPs) who are aware of this transitional stage can better address PrEP uptake and adherence. We agree that the biological, psychological, social, sexual, and other areas of development that occur during adolescence can affect adolescents' sexual behavior. ²

We believe that PCPs—such as family medicine providers—should be educated on adolescent development and how to deliver sexual health services to their adolescent patients, given that some family medicine physicians have reported that they feel underprepared in providing their adolescent patients sexual health care services. ^3,4 This provides an opportunity for medical schools, residencies, and other medical professional educational and professional development programs to train family medicine health care providers in adolescent development.

We addressed in the Discussion's “Enhancing Adolescent PrEP Uptake and Adherence” subheader that providers should be trained in and talk about HIV, their sexual behaviors, and PrEP to their adolescent patients and their parents/guardians to determine whether PrEP—and what delivery method of PrEP—best fits the needs and contexts of the adolescent. We also wrote that mass and social media campaigns could increase adolescents' and their parents/guardians' knowledge and acceptance of PrEP, thus decreasing stigma.

We included in the Limitations section that our “patient” was just that—an adolescent patient aged 13–18 years old. We communicated in the article that we encouraged future research to examine how adolescent patient characteristics—such as age—could influence provider decision making in prescribing PrEP. ¹ Indeed, prior studies ^{5 –10} have found medical students' and medical providers' intentions to prescribe PrEP to patients depend on the patient's sexual orientation, gender identity, and race. Age was not a variable that was randomized in these prior studies.

Gieseken and Ibañez critiqued that our study did not take into consideration the support of multi-disciplinary teams nor sample these team members, such as nurses, therapists, and social workers. They noted that these multi-disciplinary team members can support the PrEP knowledge, uptake, and adherence of adolescents. We agree, as we noted in the Discussion's “Changing Clinical Resources” subheader, that multi-disciplinary and triadic intervention team members (such as nurses, social workers, and other health care and health service professionals trained in having adolescent–provider, parent–provider, and adolescent–parent conversations) have a role in increasing PrEP knowledge, uptake, and adherence of adolescents.

We included that text in the article because the existence of such multi-disciplinary clinical teams was a prevalent facilitator (13.9% of respondents who reported prescribing PrEP to adolescents reported this facilitator), whereas the nonexistence of these teams was a barrier (reported by 3.4% of the total sample). We did not sample health care providers and professionals who do not have prescriptive authority (such as nurses or social workers) because the aim of the study was to examine the implementation facilitators, barriers, and strategies to PCPs prescribing PrEP.

Including these multi-disciplinary team members was outside the scope of the study; however, future research could investigate the facilitators, barriers, and strategies these health care providers and professionals have in delivering services to adolescents and their parents/guardians that identify patients who meet PrEP eligibility, educate them on the risks and benefits of PrEP use, and counsel on HIV prevention and PrEP adherence strategies. As we reported, of the 502 respondents, 485 (96.6%) were physicians, 11 (2.2%) were nurse practitioners (NPs), and 6 (1.2%) were physician assistants (PAs). Our results speak more of facilitators, barriers, and strategies of physicians than other provider types or positions, such as NPs and PAs.

However, we want to acknowledge that the prescriptive authority of NPs and PAs depends on state laws. ^11,12 Studies exclusively sampling NPs or PAs should consult whether NPs or PAs in that state have full prescriptive authority. State laws differ by what nurses, therapists, social workers, and other licensed professionals can and cannot do in their practicing state. Regardless, we agree that other health care providers and professionals—such as nurses, therapists, and social workers—have a role in improving the sexual health well-being of adolescents.