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J Int AIDS Soc. 2018 Jun;21(6):e25147. doi: 10.1002/jia2.25147.

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

Author information

1
Department of Psychology, George Washington University, Washington, DC, USA.
2
Social and Behavioral Sciences Department, Yale School of Public Health, Yale University, New Haven, CT, USA.
3
Department of Human Development and Family Studies, University of Delaware, Newark, DE, USA.
4
Columbia Law School, Columbia University, New York, NY, USA.
5
Heilbrunn Department of Population & Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA.
6
The Fenway Institute, Fenway Health, Boston, MA, USA.
7
Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard University, Boston, MA, USA.
8
Department of Population Medicine, Harvard Medical School, Harvard University, Boston, MA, USA.
9
Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, Washington, DC, USA.
10
Department of Health Promotion and Behavior, College of Public Health, University of Georgia, Athens, GA, USA.
11
Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA.
12
Disparities Solutions Center, Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, MA, USA.
13
Department of Psychology, Yale University, New Haven, CT, USA.

Abstract

INTRODUCTION:

Despite 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.

METHODS:

An 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.

RESULTS:

Willingness 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%).

CONCLUSION:

Medical students' clinical judgments were misaligned with patient risk and suggest misconceptions or personal values may undermine provision of optimal HIV prevention services.

KEYWORDS:

HIV ; health personnel; healthcare disparities; pre-exposure prophylaxis; prescriptions; sexual minorities

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