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How Prejudice in Medical Care Can Hinder PrEP Uptake (Dr. Calabrese)

Published in HIV Equal, 12/21/17, BY: GRANT SCHLEIFER

Medical trainees with highly prejudiced attitudes towards gay and bisexual men are less willing to prescribe those patients HIV pre-exposure prophylaxis (PrEP), according to a survey released in November, 2017.

The study, sponsored by the National Institutes of Mental Health, assessed 115 U.S. medical students for heterosexist beliefs (e.g. “Male homosexuality is a perversion” and “Sex between two men is just plain wrong”). These students then read about a hypothetical male patient with an HIV-positive male partner and were asked whether they would prescribe PrEP to that patient. Students with greater heterosexism were more likely to make negative judgments about their patient’s behavior – often assuming their patient would have poor PrEP adherence and more condomless sex.

The judgments healthcare providers make about their patients often have meaningful implications for the way they prescribe medication. In the study, medical students who assumed that patients would increase their rate of condomless sex if given PrEP, for example, were significantly less likely to be willing to prescribe PrEP to those patients. Such unwillingness to prescribe PrEP to eligible patients shows how medical trainee prejudice can spill over into the way they treat patients.

This is not the first study to reveal the effects of prejudice on medical trainees’ willingness to prescribe PrEP to gay and bisexual patients. Previous research has shown that medical students are significantly less willing to prescribe PrEP to black patients compared to white patients with identical medical needs. Racism may, therefore, help explain the limited access to PrEP among racial minority populations.

Sarah Calabrese, the lead author of the study and professor of clinical psychology at George Washington University, discussed how these findings may inform the way medical schools train their students.

“Including cultural competence training related to sexual diversity in PrEP education programs that target health service providers is warranted,” said Calabrese. “Evaluating the effectiveness of such programs with respect to both clinical and cultural competence outcomes is also needed.”

In recent years there has been increasing attention on how healthcare providers’ biases, including heterosexism and racism, may perpetuate poorer health outcomes among sexual and racial minorities. These biases are generally unconscious and are especially influential when providers are expected to use their discretion – as in the case of PrEP prescribing. Given that provider prejudices may persist despite providers’ best intentions, Calabrese pointed out that actions to address racial inequities will not necessarily translate to more equitable treatment for sexual minorities and other marginalized groups.

According to the study, PrEP education in medical school did not reduce the negative effects of heterosexism and racism on students’ PrEP decision-making. Future programs in PrEP education should directly address provider prejudice rather than simply teaching students about PrEP and its medical usage.

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