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

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

Lesbian, Gay, Bisexual, and Transgender Health: a Survey of Attitudes, Knowledge, Preparedness, Campus Climate, and Student Recommendations for Change in Four Midwestern Medical Schools

Medical school curricula addressing the unique healthcare needs and disparities of lesbian, gay, bisexual, and transgender (LGBT) patients are insufficient. National organizations have recommended curricular and institutional climate changes to address this problem. This study examined students’ perceived attitudes and knowledge regarding LGBT patient care and campus climate at four Midwestern US allopathic medical schools. During 2013, all medical students at the four institutions were invited to participate in the online anonymous survey. We used descriptive statistics for survey item results and qualitative methods to analyze responses to open-ended questions about curricular changes. Survey results were obtained from 34.6% of students and demonstrated that attitudes, knowledge, preparedness, and campus climate across all institutions were generally positive for LGBT patients and students. A negative correlation was found between overall campus climate and discrimination practices. Four themes emerged from students’ recommendations to improve their training, which included more clinical experiences with LGBT patients, more formal curricula on LGBT topics, establishment of safe learning environments, and addition of specific topics related to LGBT health. Due to the low prevalence of LGBT populations, reluctance to disclose sexual orientation or gender identity, and lack of LGBT-specific clinics, required experiences with LGBT patients during clinics or clerkship rotations may be more difficult in smaller urban communities in which some Midwestern medical schools are located. Potential alternatives include using multiple teaching modalities in the pre-clerkship years to expose students to LGBT-identified patients in clinical simulations and settings

Uptake of HIV Testing in Substance Use Disorder Treatment Programs That Offer On-Site Testing

Increasing rates of HIV testing within substance use disorder (SUD) treatment clients is an important public health strategy for reducing HIV transmission rates. The present study examined uptake of HIV testing among 1224 clients in five SUD treatment units that offered on-site testing in Florida, New York, and California. Nearly one third (30%) of the participants, who had not previously tested positive, reported not having been tested for HIV within the past twelve months. Women, African Americans, and injection drug users had a higher likelihood of having been tested within the past twelve months. The SUD treatment program was the most frequently identified location of participants’ last HIV test. Despite the availability of free, on-site testing, a substantial proportion of clients were not tested, suggesting that strategies to increase uptake of testing should include addressing barriers not limited to location and cost

Patterns and Predictors of Disclosure of Sexual Orientation to Healthcare Providers Among Lesbians, Gay Men, and Bisexuals

The present study sought to identify patterns and predictors of disclosure of sexual orientation to healthcare providers among lesbian, gay, and bisexual (LGB) adults. METHODS: Respondents were 396 self-identified LGB individuals ages 18–59, recruited from diverse community venues in New York City, with equal numbers of men and women and Whites, Blacks, and Latinos. Respondents were interviewed at baseline and 1-year follow-up. We assessed the relationships among disclosure of sexual orientation, demographic characteristics, health, and minority stress. RESULTS: Rates of nondisclosure to healthcare providers were significantly higher among bisexual men (39.3%) and bisexual women (32.6%) compared with gay men (10%) and lesbians (12.9%). Bivariate and multivariate logistic regression models predicting disclosure of sexual orientation indicated that patient age, level of education, immigration status, medical history, level of internalized homophobia, and degree of connectedness to the LGB community were significant factors, along with sexual identity. Nondisclosure of sexual orientation was related to poorer psychological wellbeing at one year follow-up. CONCLUSION: Our findings suggest that interventions targeting sexual minorities ought to carefully tailor messages to subpopulations. In particular, interventionists and clinicians ought to be mindful of differences between bisexually- and gay/lesbian-identified individuals