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Some of the Americans who need PrEP the most face the greatest barriers to getting it
Roger Pebody, 2016-10-25 17:00:00
The personal values and moral judgements of healthcare
providers are likely to interfere with the appropriate provision of 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
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 FDA 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
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.