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AIDS Patient Care STDS. 2019 Feb;33(2):79-88. doi: 10.1089/apc.2018.0166.

Considering Stigma in the Provision of HIV Pre-Exposure Prophylaxis: Reflections from Current Prescribers.

Author information

1
1 Department of Psychology, George Washington University, Washington, District of Columbia.
2
2 The Fenway Institute, Fenway Health, Boston, Massachusetts.
3
3 Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard University, Boston, Massachusetts.
4
4 Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts.
5
5 Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia.
6
6 Department of Population Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts.
7
7 Social and Behavioral Sciences Department, Yale School of Public Health, Yale University, New Haven, Connecticut.
8
8 Columbia School of Nursing, New York, New York.
9
9 University of Michigan Medical School, Ann Arbor, Michigan.
10
10 Columbia Law School, Columbia University, New York, New York.
11
11 Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, New York.
12
12 Department of Health Promotion and Behavior, College of Public Health, University of Georgia, Athens, Georgia.
13
13 Disparities Solutions Center, Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts.
14
14 Department of Psychology, Yale University, New Haven, Connecticut.
15
15 Chronic Disease Epidemiology Department, Yale School of Public Health, Yale University, New Haven, Connecticut.

Abstract

Efforts to identify and address social inequities in HIV pre-exposure prophylaxis (PrEP) access are urgently needed. We investigated early-adopting PrEP prescribers' beliefs about how stigma contributes to PrEP access disparities in health care and explored potential intervention strategies within the context of PrEP service delivery. US-based PrEP prescribers were recruited through professional networks and participant referrals. Qualitative interviews were conducted, transcribed, and thematically analyzed. Participants (nā€‰=ā€‰18) were primarily male (72%); white (39%) or Asian (33%); and heterosexual (56%). Most practiced in the Northeastern (67%) or Southern (22%) United States; were physicians (94%); and specialized in HIV/infectious disease (89%). Participants described multiple forms of structural and interpersonal stigma impeding PrEP access. The requirement that PrEP be prescribed was a perceived deterrent for populations with medical mistrust and/or low health literacy. Practice norms such as discussing PrEP only in response to patient requests were seen as favoring more privileged groups. When probed about personally held biases, age-related stereotypes were the most readily acknowledged, including assumptions about older adults being sexually inactive and uncomfortable discussing sex. Participants criticized providers who chose not to prescribe PrEP within their clinical practice, particularly those whose decision reflected personal values related to condomless sex or discomfort communicating about sex with their patients. Suggested solutions included standardizing PrEP service delivery across patients and increasing cultural competence training. These early insights from a select sample of early-adopting providers illuminate mechanisms through which stigma could compromise PrEP access for key populations and corresponding points of intervention within the health care system.

KEYWORDS:

HIV; clinical decision making; health care disparities; patient care; pre-exposure prophylaxis; prejudice

PMID:
30715918
DOI:
10.1089/apc.2018.0166

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