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Providers PrEP: Identifying Primary Health care Providers' Biases as Barriers to Provision of Equitable PrEP Services
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JAIDS Oct 1 2021
When considering whether to discuss and prescribe PrEP, racial biases manifested in expectations that Black CGW will be less able to adhere to PrEP relative to White CGW. ..... The finding in the Journal of Acquired Immune Deficiency Syndrome, adds to mounting evidence that practitioners who know about and are willing to prescribe PrEP — even those participating in federal projects to increase PrEP among Black Americans — still fail to refer Black people for PrEP and, when faced with people who might qualify, hesitate to prescribe because of worries related to Black patients' behaviors.
The clinicians were also asked whether they would discuss PrEP with the women and whether they would write a prescription for it.....There was a moderate level of concern that PrEP would lead women to practice sexual behaviors that put them at higher risk for HIV; the mean score on that factor was 2.63.....The more likely clinicians were to express racist beliefs on the CoBRAS subscales, the less likely they were to talk to their Black patients about PrEP or to prescribe it to them....."Those providers assumed lower levels of adherence, that [Black women] would be less adherent to the regimen," Hull said.....Concern about adherence was a troubling finding with regard to women who might benefit from PrEP and who don't know about it, said Hull — especially in communities where the rates of untreated and therefore transmissible HIV are high. But it's also troubling for practitioners.
Primary care practitioners who scored higher on a scale indicating unconscious or conscious racism were less willing to discuss HIV preexposure prophylaxis (PrEP) with Black women, citing concerns that the women wouldn't be able to take the daily HIV prevention pill every day.
Mounting evidence demonstrates that health care provider recommendations are a critical factor in women's awareness, willingness, and ability to uptake PrEP.6 As a biomedical intervention, primary health care providers are gatekeepers to the provision of information about PrEP13 and access to prescriptions. However, in clinical settings, Black people routinely experience racism, sexism, and stigma14–17 that cultivates medical distrust,18 results in lower quality clinical encounters,19,20 reduces health care quality,21 and delays indicated treatment.22–25 There is growing evidence that health care providers make clinical judgments about the appropriateness of PrEP for a patient based on unconscious and conscious stereotypes and prejudice15,26,27 that likely disadvantage women, drug users, the poor, and Black people.15,28 Black CGW face unique barriers to PrEP awareness and access in clinical encounters because they are situated at the intersection of multiple disadvantaged social locations.
Regarding expectations that women would be able to take a pill a day, the mean score was 3.36. When the investigators correlated CoBRAS scores with PrEP clinical judgment scores, another pattern emerged: The more likely clinicians were to express racist beliefs on the CoBRAS subscales, the less likely they were to talk to their Black patients about PrEP or to prescribe it to them....."Those providers assumed lower levels of adherence, that [Black women] would be less adherent to the regimen," Hull said.
Unfortunately, she said, it's not the first time PrEP research has revealed that clinical judgment can be influenced by race. Previous research using CoBRAS to assess clinicians' willingness to discuss and prescribe PrEP with gay and bisexual men found that pracitioners were less likely to be willing to prescribe PrEP to gay and bisexual Black men
In that study, the clinician's clinical judgment was that the Black men but not the White men would have more risky sex if they used PrEP. Data indicate that despite higher rates of HIV in gay and bisexual Black male communities, Black men engaged in safer sexual behavior and got tested for HIV more often than their White peers.
The findings add to growing data that clinical judgment and actions are placing Black people who could benefit from PrEP at a disadvantage. Indeed, PrEP could transform rates of HIV among Black Americans, said Dawn K. Smith, MD, epidemiologist and biomedical intervention implementation activity lead at the Division of HIV Prevention at the Centers for Disease Control and Prevention (CDC). Smith was not involved in the study.
"Yes, you should override your clinical judgment" when it comes to who you think will or won't be able to take a pill every day, she said. Smith has long worked on the CDC's guidelines for PrEP prescribing. A draft of the new guidelines suggests that clinicians should talk to every sexually active teen and adult about PrEP and should offer a prescription to anyone who comes in asking for one, even if they don't acknowledge high-risk behaviors, Smith said.
Nearly half of people who qualify for PrEP are Black, but data show that only 8% of Black Americans who could benefit from PrEP are taking it. Among cisgender women, 60% of new HIV diagnoses are in Black women. The need is so acute that the President's Advisory Council on HIV/AIDS includes a record number of Black women this year. The current AIDS czar calls the inclusion of Black women an intentional move to highlight Black women's leadership as well as the need for PrEP among Black women.
There is a critical gap in evidence-based interventions aimed to reduce provider bias in their interactions with populations of Black CGW to reduce HIV infections. This study provides evidence to support the development of interventions that address the mechanisms that work to thwart optimal care. .....There is also a dearth of empirical evidence of the ways provider biases obstruct provision of PrEP for Black CGW. This knowledge is critical to the development of interventions designed to train health care providers to identify and overcome biases in their interactions with Black CGW. This study provides empirical knowledge of how biases shape health care providers' willingness to discuss and prescribe PrEP to Black CGW.
......https://themedicalprogress.com/2021/10/05/racial-factors-may-affect-prep-discussions-with-black-women/
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When considering whether to discuss and prescribe PrEP, racial biases manifested in expectations that Black CGW will be less able to adhere to PrEP relative to White CGW. Thus, there is an analogous process at work to disadvantage Black people, but the specific pathways of effects may vary across patient populations (ie, MSM or CGW). Consistent with the intersectionality framework, these results illustrate the importance of understanding the ways racial bias affects patient–provider communication and also shapes clinical decision making differently for groups at different intersectional locations.
The CGW patient in the vignette was eligible for PrEP, given that she presented with a recent STI diagnosis and reported inconsistent condom use, in addition to her geographic risk in an HIV hotspot. Per both the WHO and CDC guidelines, it would have been not only appropriate but indicated for all providers to discuss PrEP with this patient. Our data show that providers were not only less than unanimous in their willingness to discuss PrEP with this CGW but also that their unwillingness was racially biased, based on presumptions about adherence to PrEP. This finding illustrates an important mechanism by which gaps in awareness and knowledge of HIV prevention innovations emerge and widen. Racially biased treatment that produces knowledge gaps not only impedes access and patients' abilities to self-advocate in their HIV prevention but also cultivates distrust, which further impedes optimal health care.46The spiral of biased treatment, distrust, and suboptimal care will continue and become more deeply entrenched as advances in scientific knowledge reveal important limitations and side effects of PrEP. Although increasing numbers and types of biomedical prevention tools can be beneficial in giving individuals more prevention options from which to choose, these compounding factors can also thwart efforts to end the epidemic and close inequities in HIV infection.
This research contributes to the mounting evidence that although providers know about PrEP, they are not linking Black CGW to PrEP in accordance with the demonstrable need.11,44 A 2017 survey demonstrated that among 527 nurse practitioners, internal, family, HIV, and infectious disease doctors in 10 cities, more than 86% were aware of PrEP45; however, compared with HIV care providers, primary care providers are significantly less willing to prescribe PrEP.45Even among HIV care providers, CGW face significant barriers to access, as a 2016 study demonstrated that HIV care providers are most likely to prescribe PrEP for MSM and least likely to prescribe it for heterosexual women and men and injection drug users.28 This literature, corroborated by this study, suggests that provider willingness to recommend and prescribe PrEP to Black CGW may present significant barriers to equitable provision.
We anticipated that health care providers' clinical decisions related to PrEP would be informed by racial biases when the patient was Black (vs. White). For example, experimental evidence shows that medical students are less likely to prescribe PrEP to Black MSM compared with White MSM because of expectations of risk compensation, which are likely rooted in stereotypes about Black hypersexuality.15 This evidence is not conclusive, however. In a replication of that research, Calabrese et al34 found little evidence for racist clinical decision making among medical students in the provision of PrEP to a gay male patient. Still, other evidence shows that health care providers' (un)willingness to prescribe ARVs is shaped by stereotypes about patient adherence, particularly for minorities, substance users, women, and the poor.19,28
Providers PrEP: Identifying Primary Health care Providers' Biases as Barriers to Provision of Equitable PrEP Services
Abstract
Background:
Despite their disparately high HIV incidence and voiced willingness to use pre-exposure prophylaxis (PrEP), Black cisgender women's knowledge and uptake of PrEP are low, especially relative to White cisgender women and men who have sex with men. Mounting evidence demonstrates that health care provider recommendations are a critical factor in women's awareness, willingness, and ability to uptake PrEP. Health care providers may make clinical judgments about who is (not) a good candidate for PrEP based on unconscious and conscious stereotypes and prejudice.
Setting:
We conducted an online experiment among N = 160 health care providers with prescribing privileges in the 48 HIV hotspot counties.
Method:
Providers received 1 of 4 vignettes about a PrEP eligible woman. Vignettes varied by patient race and substance use status. Then, providers reported their willingness to discuss PrEP with the patient and willingness to prescribe PrEP to her.
Results:
We tested 2 models predicting providers (1) willingness to discuss and (2) willingness to prescribe PrEP, contingent on their racial attitudes. Providers who scored high on a modern racism measure were less willing to discuss and prescribe PrEP to the Black patient. These effects were mediated by provider perceptions of patients' abilities to adhere to PrEP, but not their expectations of risk compensatory behaviors.
Conclusions:
Our findings highlight the importance of applying an intersectional lens in documenting the processes that exacerbate inequities in PrEP use. This study provides evidence to support the development of interventions that address the mechanisms that work to thwart optimal care.
Participants were N = 174 health care providers, practicing in 1 of 48 HIV hotspot counties,37 with a mean of 21.06 (SD 8.59) years of experience, practicing in 139 different zip codes. The sample was 69% White, 19% Asian, 2.9% Black, and 1.1% Hawaiian or Pacific Islander; 8% identified as other. The average age of the participants was 52.43 (SD 9.56) years. Their specializations included internal medicine (47.2%), family medicine (37.4%), infectious diseases (4.9%), obstetrics and gynecology (3.7%), emergency medicine (1.8%), preventative medicine (0.6%), and other specializations (4.3%). On average, respondents reported that they were "moderately familiar with PrEP" (mean = 3.23, SD 1.10, range: 1 to 5). There were no significant differences by condition in professional specialization (F3, 156 = 0.42, ns), PrEP knowledge (F3, 156 = 0.41, ns), or years in practice (F3, 156 = 1.12, ns). Respondents reported that they were "somewhat comfortable" (mean 6.19, SD 1.21, range: 1 to 7) discussing HIV risk factors with patients and they "rarely" to "sometimes" (mean 2.53, SD 1.05, range: 1 to 5) prescribed PrEP in the past 12 months. There were no significant differences between condition for comfort discussing HIV risk (F3, 156 = 0.44, ns) or PrEP prescribing experience (F3, 156 = 0.44, ns). Descriptive statistics and correlations for the main study variables are shown in Table 1. Across conditions, health care providers' responses to the COBRA tended toward the midpoint of the scale. The COBRA comprises Institutional Discrimination (mean 3.41, SD 0.99), Blatant Racial Issues (mean 2.32, SD 0.99), and Unawareness of Racial Privilege (mean 3.13, SD 1.06) subscales. Expectations of risk compensation tended above the midpoint of the scale. On average, providers were moderately confident that the patient would be adherent. Most respondents maybe, probably, or definitely would discuss (80%) or prescribe (78.7%) PrEP to this patient.
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