Study design and settings

This cross-sectional survey was conducted between January 2024 and April 2025 among healthcare providers at a medical school and its affiliated teaching hospital in North Louisiana. As part of the Southern United States, Louisiana consistently ranks among the states with the highest HIV diagnosis rates, underscoring the importance of examining PrEP implementation within this high-burden setting [4,5].

Participants and recruitment

Eligible participants included physician faculty members, residents, and fellows actively involved in patient care from the following departments: internal medicine, emergency medicine, pediatrics, family medicine, and obstetrics and gynecology. Participants were recruited using convenience sampling through institutional listserv email invitations, printed flyers posted in clinical and academic areas, and brief presentations during departmental grand rounds and morning reports. Although convenience sampling was employed within a single academic medical center, an estimated sample size was considered to ensure adequate precision of proportion estimates. Since there were no prior estimates of the proportion of providers reporting the outcomes of interest (e.g., PrEP prescribing), a conservative assumed proportion of 50% was used, as recommended by Lwanga and Lemeshow [7], in standard sample size formulas for estimating proportions in cross-sectional studies, because this produces the largest required sample size. Assuming a 95% confidence level and a margin of error of ±10 percentage points, the minimum estimated sample size required was approximately 96 participants. A total of 104 healthcare providers completed the survey, exceeding the recommended threshold. Incomplete responses were excluded using listwise deletion, resulting in a final analytic sample of 102. Recruitment materials included a Quick Response (QR) code and a direct hyperlink to the electronic survey, allowing providers to access the questionnaire via computer, tablet, or mobile device. Upon accessing the survey, participants were first presented with an informational letter describing the purpose of the study, the voluntary nature of participation, and the anonymous handling of responses. Participants indicated their willingness to participate by selecting either “agree” or “disagree.” Those who declined were excluded from the survey. Individuals who agreed completed eligibility screening questions; only eligible participants were permitted to proceed to the full survey, while ineligible respondents were automatically screened out, and the survey was closed.

Measures

The survey instrument was developed using previously validated items assessing provider knowledge, attitudes, and PrEP prescribing behaviors [8]. Items were adapted to reflect the regional clinical context and study objectives. The questionnaire was pilot-tested among physicians involved in the study to evaluate clarity, readability, and survey flow. Minor revisions were made prior to distribution to improve question wording and overall usability. Physicians who participated in the pilot test were not included in the final analytic sample.

Provider knowledge was assessed using self-reported familiarity with PrEP, awareness of prescribing guidelines, and prior training exposure. Prescribing practices were measured using items assessing whether providers had discussed or prescribed PrEP and their perceived confidence in identifying eligible patients.

The first set of outcomes was based on physician prescribing practices for PrEP. Participants were asked the following five questions: 1) What percentage of your patients do you perceive as significantly at risk for HIV? 2) Have any patients asked about PrEP? 3) Have you discussed PrEP with a patient? 4) Have you ever prescribed PrEP to a patient? and 5) Have you referred a patient to another provider for PrEP? The first question had four possible responses: less than 5%, 6% to 10%, 11% to 15%, and greater than 16%. The remaining questions had yes and no responses.

The second set of outcomes was based on barriers to PrEP prescription. Participants were asked whether they had encountered barriers based on five possible factors: 1) A lack of provider training/education regarding PrEP; 2) A lack of clinic guidelines/protocol for prescribing/monitoring PrEP; 3) A lack of clinical and lab monitoring requirements; 4) Staffing/time constraints related to risk reduction and PrEP adherence counseling (medication knowledge/counseling, adverse effects, etc.); and 5) A lack of insurance coverage and out-of-pocket patient costs for PrEP and related care (e.g., lab work).

To investigate physicians’ perceptions of PrEP, participants were asked the following four questions: 1) How effective do you think PrEP is in preventing acquisition of HIV/AIDS?; 2) How would you rate your knowledge of PrEP?; 3) PrEP will promote risky sexual behavior?; and 4) How likely do you think a patient would be to decrease their sexual risk as a result of PrEP use? Responses to the first question, which measured PrEP effectiveness, were “very effective,” “moderate,” and “slightly effective.” The responses were reverse-coded to indicate increasing effectiveness. Responses to the second question, which measured PrEP knowledge, were “poor,” “fair,” “good,” “very good,” and “excellent.” Responses to the third question, which measured whether PrEP would promote risky sexual behavior, were “agree,” “neither agree nor disagree,” and “disagree.” Responses were reverse-coded to indicate an increasing perception of risky sexual behavior. The last question measured the decrease in sexual risk as a result of PrEP use; its responses were “very likely,” “likely,” “slightly likely,” and “not likely.” The responses were reverse-coded to reflect increasing agreement that PrEP use decreases sexual risk. Demographic covariates collected included age, sex, race/ethnicity, specialty, hospital role (faculty, resident, fellow, other), and years in practice.

Data management and analysis

Survey data were collected electronically using REDCap (Research Electronic Data Capture), a secure web-based platform, and exported for analysis in IBM^® SPSS 23.0. Descriptive statistics (frequencies, percentages, means, and standard deviations) were calculated for all variables. Associations between provider characteristics, knowledge, and prescribing practices were examined using multivariable logistic regression models. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were reported. Covariates included in regression models were age, sex, race/ethnicity, specialty, role, and years in practice. Linear regression was used where outcomes were continuous.

Ethical approval

The study protocol was reviewed and approved by the Louisiana State University Health Sciences Center–Shreveport Institutional Review Board (IRB #00002527). The requirement for written informed consent was waived due to the minimal-risk nature of this voluntary, anonymous survey. No personally identifiable information was collected, and all responses were stored on secure, password-protected servers accessible only to the research team.

Demographic and professional characteristics

Demographic and professional characteristics of study participants are presented in Table 1. The study included 102 health care providers practicing in North Louisiana across various clinical specialties and training backgrounds.

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Table 1. Demographic and professional characteristics of healthcare providers from North Louisiana (N = 102).

https://doi.org/10.1371/journal.pone.0346890.t001

PrEP-related practices and reported barriers

As shown in Table 2, 72.5% (n = 74) of participants had never prescribed PrEP, and 48% (n = 49) had never discussed it. Reported barriers were predominantly training-related (Fig 1).

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Table 2. PrEP related practices and reported barriers among healthcare providers from North Louisiana (N = 102).

https://doi.org/10.1371/journal.pone.0346890.t002

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Fig 1. PrEP prescribing and discussion among healthcare providers (N = 102).

https://doi.org/10.1371/journal.pone.0346890.g001

Percentage of healthcare providers who reported discussing PrEP with patients and ever prescribing PrEP.

Provider knowledge and PrEP prescribing behaviors

Provider perceptions and knowledge of PrEP were strongly associated with prescribing behaviors. Providers with greater knowledge were over five times more likely to discuss PrEP (aOR: 5.10, 95% CI: 2.31–11.27) and more than three times more likely to prescribe it (aOR: 3.29, 95% CI: 1.72–6.30) compared with providers reporting lower knowledge levels (Table 3).

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Table 3. Multivariable linear and logistic regression predicting provider prescribing practices (N = 102).

https://doi.org/10.1371/journal.pone.0346890.t003

Provider knowledge and PrEP prescribing barriers

Greater knowledge was also associated with reduced odds of perceiving institutional barriers, including lack of training (aOR: 0.52, 95% CI: 0.32–0.85) and absence of protocols (aOR: 0.38, 95% CI: 0.23–0.63). In contrast, providers who believed that PrEP reduces patient sexual risk were more likely to report systemic limitations such as unclear clinical protocols and time or staffing constraints (Table 4).

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Table 4. Multivariable logistic regression predicting perceived barriers to prescribing PrEP (N = 102).

https://doi.org/10.1371/journal.pone.0346890.t004

Key findings

This study identified substantial gaps in PrEP prescribing among healthcare providers in North Louisiana, driven primarily by limited provider knowledge and institutional barriers. These findings highlight the critical role of provider preparedness and health system infrastructure in expanding access to HIV prevention. In a study among clinicians highly engaged in HIV care, only 54% had ever prescribed PrEP, indicating that even providers working with patients at risk for HIV face barriers to offering PrEP [8]. While providers in our study acknowledged that many of their patients may be at high risk for HIV, actual prescription rates of PrEP in Louisiana remain low [9]. Assessing HIV risk may often be dependent on patient-reported sexual risky behaviors, which may be limited by stigma or discomfort [9]. Moreover, relying on self-report and current clinical criteria can lead to systematic exclusion of vulnerable individuals who could benefit from PrEP [10]. Studies show that HIV risk alone does not lead to higher PrEP use unless supported by provider education and structural readiness for stigma-free PrEP conversations [2,3,11]. Our participants reported inadequate institutional support and the absence of standardized prescribing guidelines or systems, which is similar to results from previous studies in the South, as well as other research in England and Brazil [12].

Our findings reinforce the importance of improving healthcare providers’ knowledge regarding PrEP. Providers with greater knowledge about PrEP were over five times more likely to discuss it with patients and three times more likely to prescribe it to them. These results align with previous studies, which have consistently shown that knowledge is a key facilitator of PrEP implementation [12–14]. A lower knowledge of prescribing guidelines, uncertainty of how to appropriately identify possible candidates for PrEP, and a lack of PrEP-specific training were also associated with decreased prescribing rates among healthcare providers due to inexperience with PrEP and other HIV medications. However, providers who showed increased familiarity with PrEP as a result of specialized training or patients requesting it, also showed decreased knowledge gaps concerning PrEP and increased rates of PrEP prescription [15,16].

Policy and programmatic implications

Significantly, knowledge gaps were also tied to perceptions of institutional barriers, suggesting that institutional support may play a critical role in expanding PrEP uptake. Many healthcare providers in this study indicated insufficient training related to PrEP and identified the lack of clinical guidelines as a barrier. Previous research indicates the need for educational interventions, innovative approaches to the delivery of HIV care, and efforts to reduce stigma around PrEP [17]. Without these measures, PrEP utilization will remain low, especially among those who need it the most. Interdisciplinary care teams, PrEP navigators, and the development of standard prescribing protocols may also address these limitations [18,19]. Digital communications, like two-way digital messaging, have been recognized as best practices for enhancing provider-patient engagement and ensuring that patients continue taking PrEP [20,21]. Implementing a standard of quarterly clinical lab monitoring appointments in conjunction with virtual clinic visits provides a more patient-centered approach and may increase patient compliance with PrEP treatment [22]. Another strategy to overcome systemic barriers includes embedding prompts into electronic health records and integrating PrEP screening into routine sexual health checkups [23].

Occupational barriers preventing PrEP prescription have also been identified. High-demand, fast-paced clinical and hospital settings allow insufficient time for physicians to provide adequate education surrounding PrEP and HIV prevention, consult with insurance companies to establish coverage, and manage patient follow-up [24,25]. This is exacerbated in under-resourced areas of the Southern United States, where providers experience a large patient load and limited public health infrastructure [12,26]. One proposed solution to alleviate the time restriction is to further expand the roles of HIV and PrEP counselors and create a specific protocol concerning PrEP care to allocate roles to nurses, pharmacists, and other members of the healthcare team, which would reduce the time constraint placed on the physician [25].

Despite national initiatives such as the “Ready, Set, PrEP’ program and Gilead’s Advancing Access initiative, cost and insurance issues remain a barrier for providers to prescribe PrEP to their patients in Louisiana, as providers are often unaware of these programs [27,28]. The lack of comprehensive HIV prevention infrastructure has enabled a structural epidemic to continue, particularly among low-income, uninsured, and racial/ethnic minority populations [4]. These barriers reflect broader structural inequities that continue to shape HIV prevention efforts in the Southern United States. In states like Louisiana, underfunded public health systems and entrenched stigma have disproportionately impacted low-income communities and people of color. The National HIV/AIDS Strategy (NHAS) for 2022–2025 aims to eliminate the HIV epidemic in the United States by 2030. It requires a whole-of-government effort to address these disparities by integrating HIV prevention into initiatives that promote health equity and social justice [29]. These findings highlight the need for systemic interventions at the institutional level to improve PrEP prescribing via multitiered strategies that include provider training, streamlined protocols, and team-based models of care rather than solely relying on individual provider champions.

Moreover, interventions must address the intersectional realities of care delivery. For instance, obstetrics and gynecology providers may encounter cisgender women at risk for HIV, yet receive little to no PrEP-specific training [30]. Emergency department physicians also encounter at-risk patients, creating an opportunity for PrEP conversations and prescriptions; however, they lack the training and support to provide such services [31]. Future studies should investigate the interaction between provider identity and specialty on prescribing behaviors and attitudes.

Finally, the expansion of PrEP into non-traditional settings, including mobile clinics, pharmacies, telehealth platforms, and community-based organizations, has shown promise in addressing access inequities [23]. These models may be particularly effective in places like Louisiana, where a lack of healthcare and mistrust of the medical system further compound the risk of HIV transmission. Previous studies have shown that medical mistrust is associated with decreased PrEP awareness, willingness to try PrEP, and adherence, with targeted interventions showing an increase in positive outcomes among minority populations [32]. Other identified barriers to PrEP access include decreased access to PrEP providers, inadequate health insurance or financial resources, and limited health literacy [5]. Community programs and mobile PrEP clinics that offer affordable, low-cost, or no-cost services have been successful in alleviating some of the identified barriers to patients’ knowledge of PrEP and access to PrEP prescriptions and treatment [33].

Limitations and future research

Several limitations should be considered when interpreting these findings. First, due to the cross-sectional design, causal inferences cannot be established. Second, self-reported data on prescribing practices and attitudes are subject to social desirability and recall bias. However, anonymous survey administration may have reduced the likelihood of socially desirable responses. Additionally, findings may not be generalizable beyond academic-affiliated providers in the Southern United States. Finally, while the survey assessed key provider- and system-level barriers, it did not include qualitative data that could further elucidate institutional culture, stigma, or provider–patient communication dynamics. Future research should incorporate multi-site designs, qualitative methods, and longitudinal approaches to understand how organizational interventions influence prescribing PrEP across the Southern United States.