The personal values and moral judgements of healthcare providers are likely to interfere with the appropriate provision of pre-exposure prophylaxis (PrEP), Sarah Calabrese of Yale University told the HIV Research for Prevention conference (HIVR4P) in Chicago last week. When medical students were given hypothetical scenarios of gay men seeking PrEP, they were less willing to provide it to men who were not monogamous and to men who acknowledged not using condoms. Men at a lower risk of acquiring HIV had a greater chance of getting PrEP.
“It is critical that PrEP access be governed by science and not by personal values,” Calabrese said.
Today’s medical students are tomorrow’s healthcare providers, she argued. Nonetheless, a limitation of the study is that it enrolled students before their training is complete and before they gain clinical experience.
Recruited online, 111 students at two medical schools in the north east of the US completed a brief survey. They were given background information on the evidence for PrEP, its approval by the US Food and Drug Administration and some arguments for and against it. The key question was, “Please rate how likely you are to prescribe to the patient described based on the information given.”
The hypothetical patients all represented gay men at raised risk of HIV. Six scenarios were presented, varying two key elements.
For a gay man in a monogamous relationship with an HIV-positive man who was not on treatment, 93% were willing to prescribe PrEP if the couple planned to continue to use condoms. But if the monogamous couple were already not using condoms, only 53% would be willing to prescribe. And if the couple planned to stop using condoms if PrEP was provided, just 27% of medical students were willing to prescribe PrEP.
“This pattern is paradoxical to patient risk,” Calabrese commented. “The patient who is at lowest risk is the one who is going to sustain his condom use, but he is the person who has the best access to PrEP.” This is likely to penalise patients who are honest.
The prospects for a gay man who has multiple partners of unknown HIV and treatment statuses were poorer. If he planned to continue using condoms, 86% would prescribe PrEP; if he was already not using condoms, 45% would provide PrEP; and if he planned to stop using them, 28% would be willing to prescribe PrEP.
The differences, both between different approaches to condom use and between monogamous and non-monogamous men, were statistically significant.
The survey also asked about which reasons for discontinuing condom use were considered acceptable by the medical students. Just 13% thought it acceptable to stop using condoms to improve sexual functioning, 14% to increase pleasure and 23% to enhance intimacy or emotional connection.
However, 69% felt that discontinuing condom use for the purposes of conception would be acceptable. This suggests heterosexism, Calabrese argued. She also noted that in objectively considering the risk of acquiring HIV, the reason why a person does not use condoms is irrelevant.