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

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 (n = 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 earlyadopting providers illuminate mechanisms through which stigma could compromise PrEP access for key populations and corresponding points of intervention within the health care system.

Perceptions of Patient HIV Risk by Primary Care Providers in High-HIV Prevalence Areas in the Southern United States

“…Perceptions of having low-risk patient populations while working in geographic areas with high prevalence of HIV infection suggest that education regarding local HIV epidemiology may be warranted to ensure that PCPs are aware; this may help PCPs take every opportunity to provide HIV prevention and education during clinical visits with patients. Previous research has shown that providers may hold misconceptions about patients, including age-related stereotypes (i.e., older patients being sexually inactive), 25 which our data corroborate.…”

“…HIV-related stigma exhibited by health care workers in the South is prevalent, and provider characteristics such as race, religion, and clinic type may predict stigmatizing attitudes. [26][27][28] Research has also shown that personal values held by providers may interfere with discussing sexual behaviors with their patients, 25 and patient anticipated stigma in health care settings has been correlated with lower adherence to ART. 29 This underscores that targeted educational and stigma reduction efforts with providers in the southern United States, like those who participated in this study, are warranted.…”

Perceptions of and interest in HIV pre-exposure prophylaxis use among adolescent girls and young women in Lilongwe, Malawi

“…Once implemented, the effect of PrEP availability on these outcomes should be monitored and evaluated. Despite the importance of monitoring this potential unintended consequence of PrEP use, previous evidence suggests that PrEP use does not necessarily lead to risk compensation and cessation of condom use, but rather enhances informed choices [18].…”

Health Care Provider Barriers to HIV Pre-Exposure Prophylaxis in the United States: A Systematic Review

“…Several studies found that stigma and biases were influential barriers to PrEP prescription. 24,26,30,36,42,44,48 In one qualitative study, researchers highlighted the negative influence of providers' race, gender, and age biases on PrEP decision-making. Physicians described how their own personal values related to sex, including discussing sexual activity with LGBTQ individuals, were barriers to PrEP prescription.…”