Reducing Bias and Increasing PrEP

Posted in: News, News 2017

A study published in the journal AIDS Patient Care and STDs in April 2017 indicates that physicians who prescribe pre-exposure prophylaxis (PrEP) do not see an increase in risky sexual behaviors in their patients.

Previously, some doctors feared that prescribing PrEP would encourage their patients to engage to riskier sexual practices and reduce their condom use. However, the study shows that early-adapting prescribers of PrEP see no change in sexual behavior and believe that the stigma surrounding PrEP is unwarranted.

Study lead author Sarah Calabrese, Ph.D., an assistant professor of clinical psychology at George Washington University in Washington, D.C., says that people vary their sexual habits, but most keep their condom use at the same level.

“In a lot of the research that has been done with health-care providers, one of the barriers to prescribing PrEP that comes up repeatedly is concern about sexual-risk compensation, by which I mean that patients will increase their sexual risk-taking as a result of a perceived decrease in HIV susceptibility when on PrEP,” Dr. Calabrese says. “Although research on patient behavior during real-world PrEP use is limited at this point, from what I’ve seen published, it seems like the majority of people do not change their patterns of condom use when taking PrEP. For many PrEP users, that is because they didn’t use condoms to begin with, so they can’t reduce their condom use because they are already not using condoms. While it seems like the majority of people who use PrEP don’t use condoms, there is certainly variability.”

So if taking PrEP doesn’t lead to riskier sex for the majority of people, why do so many Black gay men still experience trouble obtaining a PrEP prescription? And what stops doctors from prescribing a lifesaving drug like Truvada to their most vulnerable patients?

One possible reason is lack of knowledge. It may be hard to believe, but 1 out of 3 doctors still do not know about PrEP or how it prevents HIV transmission.

Another potential reason is racial bias. Dr. Calabrese says that some of her research from a 2014 study of medical students showed that some students had a bias against Black patients.

“Half of them read a clinical vignette about a hypothetical Black MSM patient seeking PrEP, and half read about a white MSM patient in identical circumstances. All were asked to make a series of clinical decisions about the hypothetical patient based on what they read,” says Calabrese. “The Black patient was judged as being more likely to increase his sexual risk behavior if prescribed PrEP, which led to a lower intention to prescribe to him. So my early research suggests that a racial bias could be operating. We recently tried to replicate that study with a different sample of medical students, and we didn’t see that same effect. We didn’t see the same racial bias operating. So that’s promising.”

Where do we go from here? Educating Black MSM and the medical community about PrEP is one way to improve health care. Cultural-competence training for prescribing physicians is another. Ultimately, the decision to use condoms lies with the patient, but health-care providers’ ability to offer their patients accurate, complete medical information about how to protect themselves from HIV should increase the likelihood that people at risk will make healthier choices.

Candace Y.A. Montague is an award-winning freelance journalist in Washington, D.C. Her work has been featured in several online and print publications, including The Washington Post and The Grio.


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