Prevention paradox: Medical students are less inclined to prescribe HIV pre‐exposure prophylaxis for patients in highest need

Abstract

IntroductionDespite healthcare providers’ growing awareness of pre‐exposure prophylaxis (PrEP), prescription rates remain low. PrEP is an efficacious HIV prevention strategy recommended for use with condoms but still protective in their absence. Concern about the impact of PrEP on condom use and other risk behaviour is, nonetheless, among the barriers to prescription commonly reported. To understand the implications of this concern for PrEP access, we examined how medical students’ willingness to prescribe PrEP varied by patients’ condom use and partnering practices. We also assessed the perceived acceptability of various reasons for condom discontinuation with PrEP.MethodsAn online survey was distributed to 854 medical students in the Northeastern US in 2015. Participants (n = 111) were surveyed about their willingness to prescribe PrEP for each of six male patients who systematically differed in their reported condom use (sustained use, sustained nonuse, or discontinuation with PrEP) and partnering practices (single male partner with untreated HIV or multiple male partners of unknown HIV status). Participants also reported perceived acceptability of four reasons for condom discontinuation: pleasure, sexual functioning, intimacy, and conception.ResultsWillingness to prescribe PrEP was inconsistent with patient risk: When the patient used condoms and planned to sustain condom use, most participants were willing to prescribe PrEP – 93% if the patient had a single partner and 86% if the patient had multiple partners. Fewer were willing to prescribe if the patient did not use condoms and planned to sustain nonuse (53% and 45%, respectively) or used condoms but planned to discontinue use (27% and 28%). Significantly fewer participants were willing to prescribe for a patient with multiple partners versus a single partner when the patient reported sustained condom use or sustained condom nonuse. The number of participants who were willing to prescribe was similarly low for a patient with multiple partners versus a single partner when the patient reported that he planned to discontinue condom use. More participants accepted a patient discontinuing condoms for conception (69%) than for intimacy (23%), pleasure (14%), or sexual functioning (13%).ConclusionMedical students’ clinical judgments were misaligned with patient risk and suggest misconceptions or personal values may undermine provision of optimal HIV prevention services.

Barriers to the Wider Use of Pre-exposure Prophylaxis in the United States: A Narrative Review

“…In a survey of health directors in North Carolina ( N = 56), a perceived lack of suitable PrEP candidates was reported by 26% of respondents from departments not prescribing or referring individuals for PrEP [ 23 ]. Recently, a paradox concerning perception of risk and willingness to prescribe has been noted in an online survey completed by 111 medical students [ 49 ]. Results showed that willingness to prescribe was inconsistent with patient risk, with fewer students willing to prescribe PrEP if the patient was engaging in riskier behaviors such as not using condoms or having multiple partners.…”

HIV Pre-Exposure Prophylaxis (PrEP) Knowledge, Familiarity, and Attitudes among Healthcare Professional Students

“…Additionally, graduate medical courses should work to debunk racial and other stereotypes about risk compensation, as such biases impede provider willingness to prescribe PrEP (23)(24)(25)34). Future work could examine the extent to which hands-on experiences with high-risk populations (e.g., via clinical rotations) impact both willingness to prescribe and refer.…”

“…To date, there is limited data about healthcare professional students' knowledge and perceptions of PrEP as future potential prescribers. The few studies were limited to medical students (23)(24)(25)(26) and did not include other health professional students who may play an active role in PrEP care, such as those in nurse practitioner, or pharmacy training programs. Calabrese and colleagues surveyed medical students regarding the influence of patient race (23), sexual orientation (24), and sexual behavior (25) on clinical decision-making related to PrEP.…”

Addressing the Sexually Transmitted Infection and HIV Syndemic

“…Even though many individuals do not change their condom use behavior after starting PrEP, there is evidence that the concerns of some clinicians about behavioral change may lead them not to offer PrEP to MSM, particularly black MSM, 11 or reserve PrEP for heterosexual serodifferent couples attempting to conceive. 11,12 It is likely that some individuals with knowledge of the high efficacy of PrEP in preventing HIV infection will change their behavior and that higher-risk behavior is contributing to the current STI epidemic. 10 However, concerns about behavioral change after starting PrEP should not decrease the willingness of clinicians to offer PrEP.…”