Skip to content

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.

Dr. Sarah Calabrese was featured in GW Today (May 01, 2017) for her research.

Prescribing doctors believe the HIV prevention method is unduly stigmatized in the medical field and beyond, according to a GW study.

Health care

A new study that examined medical provider attitudes toward prescribing PrEP to prevent HIV found those who already prescribe it do not see a widespread increase in risky sexual behavior among their patients as a result.

The George Washington University-led study also found providers do not consider risky behavior to be a reason to discontinue or limit PrEP, which stands for pre-exposure prophylaxis. The researchers believe adopting PrEP is essential in curbing the number of new HIV diagnosis.

PrEP was approved in the United States in 2012 and is widely considered a breakthrough in HIV prevention. PrEP has been endorsed by the World Health Organization as a means to help limit the HIV/AIDS epidemic.

Physicians have previously cited concerns, however, that a prescription for PrEP might encourage patients to engage in more risky sexual behavior, such as decreasing use of condoms or increasing the number of sexual partners.

Sarah Calabrese, lead author of the paper and assistant professor in the Department of Psychology, said traditional prevention methods like condoms have not adequately addressed the HIV/AIDS epidemic.

“PrEP is a highly effective prevention option and people deserve access to it,” she said. “Our study found that providers who have already started prescribing PrEP can play a key role in improving access—not only by offering PrEP to their own patients but also by influencing their peers to overcome ideological hurdles around prescribing PrEP.”

Forty thousand people in the United States are diagnosed with HIV every year, Dr. Calabrese said. More than 1.2 million Americans are believed to be at significant risk for contracting HIV and are eligible for PrEP, however, less than 100,000 of them have been prescribed the drug Truvada for PrEP, according to research presented at the 2016 International AIDS Conference.

Researchers interviewed 19 United States-based health care providers with experience prescribing PrEP to better understand the attitudes and experiences surrounding care.

The interviews found that providers believed their role was to support patients in making informed sexual health decisions, and providers perceived the protective benefit of PrEP outweighed any increase in a patient’s risky behavior.

Providers also believed PrEP was unduly stigmatized by others within and beyond the health care community. The same negative judgments of patients and concerns about risky behavior aren’t seen with other forms of prevention like statins used to lower cholesterol.

A paper on the study, “Support your client at the space that they’re in: Pre-exposure prophylaxis (PrEP) prescribers’ perspectives on PrEP-related risk compensation,” was published in the journal AIDS Patient Care and STDs in April.

The paper argues that there is an urgent need to prepare providers to respond appropriately as public awareness about PrEP increases and more at-risk individuals actively seek out PrEP from their health care providers.

“This includes not only enhancing providers’ comfort and competence prescribing PrEP or referring patients elsewhere for PrEP care but also educating providers about reacting to patient inquiries in a sensitive and professional way,” the paper said.

This study targeted “early adopting” providers who already had experience prescribing PrEP and have overcome concerns within their own clinical practice, Dr. Calabrese said.

GW is committed to digital accessibility. If you experience a barrier that affects your ability to access content on this page, let us know via the Accessibility Feedback Form.