A Closer Look at Racism and Heterosexism in Medical Students' Clinical Decision-Making Related to HIV Pre-Exposure Prophylaxis (PrEP): Implications for PrEP Education

Sarah K Calabrese; Valerie A Earnshaw; Douglas S Krakower; Kristen Underhill; Wilson Vincent; Manya Magnus; Nathan B Hansen; Trace S Kershaw; Kenneth H Mayer; Joseph R Betancourt; John F Dovidio

doi:10.1007/s10461-017-1979-z

A Closer Look at Racism and Heterosexism in Medical Students' Clinical Decision-Making Related to HIV Pre-Exposure Prophylaxis (PrEP): Implications for PrEP Education

AIDS Behav. 2018 Apr;22(4):1122-1138. doi: 10.1007/s10461-017-1979-z.

Authors

Sarah K Calabrese^{1

2}, Valerie A Earnshaw³, Douglas S Krakower^{4

5}, Kristen Underhill⁶, Wilson Vincent⁷, Manya Magnus⁸, Nathan B Hansen⁹, Trace S Kershaw¹⁰, Kenneth H Mayer^{4

5}, Joseph R Betancourt¹¹, John F Dovidio^{10

12}

Affiliations

¹ Department of Psychology, George Washington University, 2125 G Street NW, Washington, DC, 20052, USA. skcalabrese@gwu.edu.
² Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA. skcalabrese@gwu.edu.
³ Department of Human Development and Family Studies, University of Delaware, Newark, DE, USA.
⁴ The Fenway Institute, Fenway Health, Boston, MA, USA.
⁵ Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
⁶ Columbia Law School, New York, NY, USA.
⁷ Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco (UCSF), San Francisco, CA, USA.
⁸ Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, Washington, DC, USA.
⁹ Department of Health Promotion and Behavior, College of Public Health, University of Georgia, Athens, GA, USA.
¹⁰ Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA.
¹¹ Disparities Solutions Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
¹² Department of Psychology, Yale University, New Haven, CT, USA.

Abstract

Social biases among healthcare providers could limit PrEP access. In this survey study of 115 US medical students, we examined associations between biases (racism and heterosexism) and PrEP clinical decision-making and explored prior PrEP education as a potential buffer. After viewing a vignette about a PrEP-seeking MSM patient, participants reported anticipated patient behavior (condomless sex, extra-relational sex, and adherence), intention to prescribe PrEP to the patient, biases, and background characteristics. Minimal evidence for racism affecting clinical decision-making emerged. In unadjusted analyses, heterosexism indirectly affected prescribing intention via all anticipated behaviors, tested as parallel mediators. Participants expressing greater heterosexism more strongly anticipated increased risk behavior and adherence problems, which were associated with lower prescribing intention. The indirect effect via condomless sex remained significant adjusting for background characteristics. Prior PrEP education did not buffer any indirect effects. Heterosexism may compromise PrEP provision to MSM and should be addressed in PrEP-related medical education.

Keywords: African Americans; Clinical decision-making; HIV; Pre-exposure prophylaxis; Prejudice; Sexual minorities.

Publication types

Research Support, N.I.H., Extramural
Research Support, U.S. Gov't, P.H.S.

MeSH terms

Adult
Anti-HIV Agents / administration & dosage*
Attitude of Health Personnel*
Clinical Decision-Making*
Female
HIV Infections / prevention & control*
Health Personnel
Homophobia*
Homosexuality, Male
Humans
Intention
Male
Pre-Exposure Prophylaxis*
Racism*
Risk-Taking
Students, Medical / psychology*
Surveys and Questionnaires

Substances

Anti-HIV Agents

Abstract

Publication types

MeSH terms

Substances

Grants and funding