The Role of Social Biases, Race, and Condom Use in Willingness to Prescribe HIV Pre-exposure Prophylaxis to MSM: An Experimental, Vignette-Based Study

Abstract

Introduction: Daily antiretroviral pre-exposure prophylaxis (PrEP) is a safe and effective method of preventing HIV. Clinicians' assumptions, biases, and judgments may impede access to PrEP. Specifically, concern that patients will engage in more condomless sex ("risk compensation") has been cited by clinicians as a reason for not prescribing PrEP.Methods: In this experimental study among medical students, we systematically varied race (White or Black) and condom-use behaviors (continued-use, planned-discontinuation, or continuednonuse) of a fictional patient (all men with multiple male sex partners). Participants indicated the patients' assumed adherence to PrEP, patients' overall HIV risk, and willingness to prescribe PrEP. Participants completed an implicit association test to detect implicit racism and measures of heterosexism and attitudes toward non-monogamy, which were examined as moderators of patient race and condom-use effects on participants' assumptions and ultimate willingness to prescribe PrEP.Results: Participants (N = 600) were most willing to prescribe PrEP to the continued-nonuse patient and least willing to prescribe to the planned-discontinuation patient. No differences were identified based on patient race. The continued-nonuse (vs. continued-use) patient was perceived as less likely to adhere to PrEP, which was associated with lower willingness to prescribe. Negative attitudes toward nonmonogamy exacerbated this effect. No effects of implicit racism or explicit heterosexism were identified. Conclusions: Participants were least willing to prescribe PrEP to patients who planned to discontinue condom use. Patients seeking PrEP are exhibiting agency over their sexual health, and clinicians should fulfill their role in ensuring access to this primary preventative therapy. Training and curricular reform regarding PrEP are needed.

Psychiatry and Family Medicine Residents’ Likelihood of Prescribing HIV Pre-Exposure Prophylaxis (PrEP) to Patients with Mental Illness and HIV Vulnerability

“…We systematically manipulated the psychiatric diagnosis of a fictional patient in the format of a clinical vignette, similar to previous work [30][31][32] (Fig. 1).…”

“…25 Encouragingly, previous work has not identified significant differences in likelihood of prescribing PrEP or biased judgments based on patients' race. 22,23,30,32 A majority of previous vignettebased studies were conducted with medical students, which are limited as medical students cannot practice independently, nor have they chosen a specialty. [22][23][24]26,[30][31][32] Despite increased HIV vulnerability among PLMI, to the best of our knowledge, no previous work has investigated whether a patient's psychiatric diagnosis and a provider's specialty could affect physicians' judgments and likelihood of prescribing PrEP to PLMI.…”

“…22,23,30,32 A majority of previous vignettebased studies were conducted with medical students, which are limited as medical students cannot practice independently, nor have they chosen a specialty. [22][23][24]26,[30][31][32] Despite increased HIV vulnerability among PLMI, to the best of our knowledge, no previous work has investigated whether a patient's psychiatric diagnosis and a provider's specialty could affect physicians' judgments and likelihood of prescribing PrEP to PLMI. Specifically, we sought to investigate the following: (1) Does likelihood of prescribing PrEP to a patient or the recommended form of PrEP differ based on the patient's psychiatric diagnosis (schizophrenia, bipolar disorder, major depression) compared with a patient without such a diagnosis?…”

“…Several previous, vignette-based studies have investigated assumptions about patients seeking PrEP and differences in likelihood of prescribing PrEP based on patient characteristics (e.g., sexual orientation, gender, race, reported risk factors [injection drug use vs. sexual contact], and condom use). 22–32 These studies have found decreased likelihood of prescribing PrEP to patients planning to discontinue condoms, 24,32 to heterosexual female patients, 26 and to patients using injection drugs. 25 Encouragingly, previous work has not identified significant differences in likelihood of prescribing PrEP or biased judgments based on patients' race.…”

“…25 Encouragingly, previous work has not identified significant differences in likelihood of prescribing PrEP or biased judgments based on patients' race. 22,23,30,32 A majority of previous vignette-based studies were conducted with medical students, which are limited as medical students cannot practice independently, nor have they chosen a specialty. 22–24,26,30–32…”