Can You Trust Your Clinical Judgment When It Comes to Prescribing HIV PrEP to Women? Don't Be So Sure

Heather Boerner

October 05, 2021

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.

The finding, published 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.

"This is the kind of research where you hope you have no findings," said Shawnika Hull, PhD, assistant professor of health communications at Rutgers University, New Brunswick, New Jersey, and lead author of the study, in an interview with Medscape Medical News. "Unfortunately, I did. But what we did do is learn a mechanism so that we can try to address it. What beliefs do we need to be addressing specifically? In this case, this evidence suggests that we need to be addressing beliefs about adherence."

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.

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.

Given the need, clinicians should act now, Smith told Medscape Medical News.

"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.

"You don't have to talk about PrEP at every visit — providers don't have time," she said. "But each patient needs to have this information somewhere in their care."

The study recruited 174 healthcare practitioners — primarily internal medicine doctors, family medicine specialists, and obstetricians/gynecologists, among others — through the online Qualtrics system. All of the clinicians lived and worked in areas where more than half of all HIV diagnoses were made in 2016 — areas that are the focus of resources and programs under the federal Ending the HIV Epidemic: A Plan for America, which aims to reduce new HIV transmissions by 90% by 2030. These are areas where anyone who is sexually active is more likely to encounter love interests who don't know they have HIV or who aren't engaged in care.

The clinicians in the study were mostly older (age 52), White (69%), and were veterans in their fields. They had been in practice for a mean of 21 years. For the study, practitioners read through case scenarios of women presenting in the office. The clinicians were asked to identify whether the women qualified for PrEP under CDC guidelines and what in their clinical judgment they felt regarding the women's ability to take the daily pill. They were also asked whether they thought the women would have sex without the use of a condom or would engage in other higher-risk sexual behaviors as a result of taking the pill — so-called risk compensation.

The clinicians were also asked whether they would discuss PrEP with the women and whether they would write a prescription for it.

All of the women in the scenarios were HIV negative, had private insurance, and were in "ostensibly monogamous" relationships. In addition, the women in the scenarios weren't sure about their partner's HIV status or whether their partner was faithful. In half of the four vignettes, the women in question were White; in the other half, they were Black. In addition, in half the vignettes, the women (of either race) reported some form of drug use that met criteria for problem use. The substances included alcohol, cannabis, and opioids.

Practitioners were asked how much they agreed with statements such as, "Talking about racial issues causes unnecessary tension," "Immigrants should try to fit into the culture and adopt the values of the US," "Race is very important in determining who is successful and who is not," and "Social policies such as affirmative action discriminate unfairly against White people."

All the questions came from the Color-Blind Racial Attitudes Scale (CoBRAS), which has been used in other HIV PrEP studies to determine how aware practitioners are of racial privilege, structural racism, and whether they hold conscious or unconscious beliefs about race that could color their clinical judgment.

Most participants had moderate scores regarding their understanding of PrEP, their comfort in talking about HIV risk factors with patients, and in their attitudes about race. Most had rarely prescribed PrEP in the past year. On a scale of 1 to 6, 1 indicated that the clinician completely disagreed with the statement, and 6 indicated complete agreement. CoBRAS comprises three subscales. On those, the mean score on recognizing institutional discrimination was 3.41, the mean score on espousing blatant racial issues was 2.32, and the mean score on lacking awareness of racial privilege was 3.13.

Although some clinicians expressed explicitly antiracist or racist beliefs, most participants' approach to race, as indicated by their responses on each subscale, was "neither here nor there" or "I'm not sure," Hull told Medscape Medical News. In other words, these people did not express blatantly racist beliefs, and they did not deny the existence of institutional racism or dispute the notion of racial privilege.

When it came to prescribing PrEP, the mean score on willingness to discuss the prevention pill was high — 5.6 of 6, with 6 being the highest — as was the mean score on intention to prescribe PrEP, at 5.51 of 6. 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.

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.

Their rationale?

"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.

"These are well-intentioned people who want to do some good," she said. She interprets the data not as a failing but as an opportunity to improve clinical care for those who might most benefit from PrEP.

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.

Oni Blackstock, MD, in 2018 wrote a letter to the editors of Mayo Clinic Proceedings in which she urged primary care practitioners to increase discussions about PrEP with women, calling the data an important guide for clinical behavior. Currently, there is no evidence base for strategies to change these patterns of behaviors for clinicians. There's no evidence that implicit bias training has brought about such changes, either, she said. The onus for improving clinical care for Black patients ought to be on a system that supports busy clinicians to act against biases embedded in the culture at large, not just individual clinicians who are busy seeing patients througout the day. More research needs to be conducted about which interventions to employ — standardized questionnaires for all patients, for example, or electronic medical record reminders.

While health systems and researchers figure out how to do that, she said, clinicians have the obligation to "pause and reflect on their own experiences that are playing a negative role in their assumptions about whether a patient is able to take these as prescribed.

"Research finds that people are much more likely when it's a really hectic, fast-paced environment, like an emergency department or even a busy primary care practice, people are likely to do a lot more reflexive thinking and also much more likely to stereotype people into different buckets," said primary care and HIV clinician Blackstock, formerly assistant commissioner at the New York City Health Department and now founder and executive director of the nHealth Justice. "If patients say that they're able to take it, give patients a trial, see how they're doing. Just give our patients the benefit of the doubt, because this is such an important tool, and we know that so few women have taken it up."

The study was funded by the National Institute on Drug Abuse at the National Institutes of Health. Smith and Blackstock report no relevant financial relationships. Hull previously conducted research funded by Gilead Sciences and received consulting fees from Gilead Sciences in 2018.

Heather Boerner is a science journalist based in Pittsburgh, Pennsylvania. Her book, Positively Negative: Love, Pregnancy, and Science's Surprising Victory Over HIV, was published in 2014.

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