PrEP Attitudes 'Paradoxical' Among Docs in Training

CHICAGO -- Doctors in training have paradoxical views on when they would prescribe pre-exposure prophylaxis (PrEP) largely because of a pro-condom "ideology," a researcher said here.

In a survey-based study, medical students were more likely to say they'd be willing to prescribe the pill-a-day PrEP if a hypothetical patient was consistently using condoms and planned to continue doing so, according to Sarah Calabrese, PhD, of George Washington University in Washington, DC.

But that's "paradoxical," she said, since patients who don't use condoms -- and don't plan to start -- and those who currently use them and plan to stop are precisely those who are at greatest need for PrEP, Calabrese told reporters at the HIV Research for Prevention conference.

PrEP with tenofovir/emtricitabine (Truvada) is recommended for people at high risk for HIV, and has been shown to be highly effective in men who have sex with men, Calabrese noted. But to access the treatment, they need the approval of a healthcare provider, since Truvada is a prescription drug, and there have been reports that the "gatekeepers" can sometimes be an obstacle, she said.

Indeed, MedPage Today reported last year that some physicians are erecting barriers between patients and PrEP.

Since medical students are the "providers of the future," Calabrese and colleagues decided to see what were their attitudes toward PrEP while they were still in medical school.

In an online survey, they asked how the students would react in several situations in which they were asked for a PrEP prescription.

They had six hypothetical patients, both gay men, but three in a monogamous relationship and the others engaging with several partners. And the patients had three histories with regard to condoms -- consistent use that was planned to continue, consistent use that was planned to stop after PrEP started, and consistent non-use with no plan to begin.

The students were also asked what reasons for stopping condom use would be acceptable. Stopping for the purpose of conception was the reference reason, compared with stopping for improved intimacy, pleasure, or sexual functioning.

The key finding, Calabrese said, was that the students were focused on condom use and would be unwilling to prescribe PrEP to men who said weren't using them or wanted to stop.

Whether the hypothetical patient was monogamous or not, about 90% of the respondents said they'd be willing to prescribe PrEP if the man had been and was planning to continue condom use.

In contrast, only about 30% said they’d prescribe if a patient wanted to stop using condoms and fewer than 50% said they’d do so if the man had not been using condoms.

The students were also much more likely to think they would prescribe PrEP if the decision to stop condom use was based on a desire to conceive, rather than reasons such as increasing pleasure, better sexual function, or improving intimacy.

But, Calabrese pointed, the reason for not using condoms has no effect on the risk of HIV.

Indeed, healthcare providers have to remember they're "not in control of that person's life," commented Susan Buchbinder, MD, of the San Francisco Department of Health.

"I tell providers we don't withhold statins because we think the person is going to go eat ice cream or grab a steak," she told MedPage Today.

"What we are trying to do is keep people as safe as possible," she added, which means giving them all the tools they need to protect themselves.

What would be interesting, she said, would be to replicate the study among active healthcare providers.