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An Experimental Study of the Effects of Patient Race, Sexual Orientation, and Injection Drug Use on Providers’ PrEP-Related Clinical Judgments

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Abstract

Social biases may influence providers’ judgments related to pre-exposure prophylaxis (PrEP) and patients’ consequent PrEP access. US primary and HIV care providers (n = 370) completed an experimental survey. Each provider reviewed one fictitious medical record of a patient seeking PrEP. Records varied by patient race (Black or White) and risk behavior (man who has sex with men [MSM], has sex with women [MSW], or injects drugs [MID]). Providers reported clinical judgments and completed measures of prejudice. Minimal evidence of racially biased judgments emerged. Providers expressing low-to-moderate sexual prejudice judged the MSM as more likely than the MSW to adhere to PrEP, which was associated with greater PrEP prescribing intention; sexual prejudice was negatively associated with anticipated MSM adherence. Providers judged the MID to be at higher risk, less likely to adhere, less safety-conscious, and less responsible than both the MSM and MSW; adverse adherence and responsibility judgments were associated with lower prescribing intention.

Resumen

Los sesgos sociales pueden influir sobre los juicios de proveedores de salud con respecto a la profilaxis pre-exposición (PrEP) y el consecuente acceso de los pacientes a PrEP. Proveedores de cuidados primarios y de VIH en los Estados Unidos (n = 370) respondieron una encuesta experimental. Cada proveedor leyó una historia médica de un paciente ficticio interesado en obtener PrEP. Las historias médicas variaron la raza (Negro o Blanco) y conducta de riesgo (hombre que tiene sexo con hombres [HSH], hombre que tiene sexo con mujeres [HSM], u hombre  usuario de drogas inyectables [HDI]) del paciente. Los proveedores reportaron juicios clínicos y completaron medidas sobre prejuicio. La evidencia sobre sesgos raciales en los juicios clínicos fue mínima. Los proveedores que expresaron prejuicio sexual bajo a moderado, juzgaron que el paciente HSH tendría mayor adherencia a PrEP que el paciente HSM, lo cual se asoció con mayor intención de prescribir PrEP; el prejuicio sexual se asoció negativamente con la adherencia anticipada en HSH. El paciente HDI fue percibido como en mayor riesgo, con menor adherencia, menos preocupado por la seguridad, y menos responsable que los HSH y HSM; los juicios sobre baja adherencia y responsabilidad estuvieron asociados con menor intención de prescribir PrEP.

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Data Availability

Data are available from the lead author (SKC) upon request.

Code Availability

Syntax for statistical analyses are available from the lead author (SKC) upon request.

Notes

  1. Although “MSW” and “MID” are not conventional abbreviations, we use them here (instead of the more commonly used “heterosexual man” or “PWID,” respectively) to more accurately represent the experimental conditions.

  2. There is wide variation in how the term “sexual orientation” has been conceptualized and measured in research [50, 51]. In this study, we operationalized sexual orientation behaviorally according to the respective sex—male or female—of a patient’s current sexual partner. However, we acknowledge that partner sex at any given time may not represent the full spectrum of a patient’s sexual behavior and does not reflect psychological dimensions of a patient’s sexual orientation (e.g., identity, attraction).

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Acknowledgements

The authors are grateful to the providers who generously dedicated their time and effort to study participation. We are also grateful to the American Academy of HIV Medicine, the Society of General Internal Medicine, and the other professional organizations that assisted with recruitment.

Funding

This study was funded by the National Institute of Mental Health (Grant No. NIMH; K01-MH103080; PI: S.K. Calabrese). Resources and support were contributed by the Yale University Center for Interdisciplinary Research on AIDS (Grant No. P30-MH062294), the District of Columbia Center for AIDS Research (Grant No. P30-AI117970), and the Harvard University Center for AIDS Research (Grant No. P30-AI060354), all funded by the National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH or the NIH.

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Authors and Affiliations

  1. Department of Psychological and Brain Sciences, George Washington University, 2125 G Street NW, Washington, DC, 20052, USA

    Sarah K. Calabrese, David A. Kalwicz, Djordje Modrakovic & Ana María del Río-González

  2. Department of Prevention and Community Health, George Washington University, Washington, DC, USA

    Sarah K. Calabrese

  3. Department of Human Development and Family Sciences, University of Delaware, Newark, DE, USA

    Valerie A. Earnshaw

  4. Department of General Internal Medicine, Yale University, New Haven, CT, USA

    E. Jennifer Edelman

  5. Department of Psychiatry & Behavioral Neuroscience, University of Chicago, Chicago, IL, USA

    Samuel R. Bunting

  6. Department of Epidemiology, George Washington University, Washington, DC, USA

    Manya Magnus

  7. The Fenway Institute, Fenway Health, Boston, MA, USA

    Kenneth H. Mayer & Douglas S. Krakower

  8. Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA

    Kenneth H. Mayer & Douglas S. Krakower

  9. Department of Health Promotion and Behavior, University of Georgia, Athens, GA, USA

    Nathan B. Hansen

  10. Department of Social and Behavioral Sciences, Yale University, New Haven, CT, USA

    Trace S. Kershaw & John F. Dovidio

  11. Department of Biobehavioral Health, Penn State University, University Park, PA, USA

    Joshua G. Rosenberger

  12. Department of Psychology, Yale University, New Haven, CT, USA

    John F. Dovidio

Authors
  1. Sarah K. Calabrese
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  2. David A. Kalwicz
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  3. Djordje Modrakovic
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  4. Valerie A. Earnshaw
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  5. E. Jennifer Edelman
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  6. Samuel R. Bunting
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  7. Ana María del Río-González
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  8. Manya Magnus
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  9. Kenneth H. Mayer
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  10. Nathan B. Hansen
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  11. Trace S. Kershaw
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  12. Joshua G. Rosenberger
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  13. Douglas S. Krakower
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  14. John F. Dovidio
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Contributions

Study conceptualization: SKC, VAE, EJE, MM, KHM, NBH, TSK, DSK, JFD. Data collection and analysis: SKC, DAK, DM. Manuscript preparation, review, and revision: SKC, DAK, DM, VAE, EJE, SRB, AMRG, MM, KHM, NBH, TSK, JGR, DSK, JFD.

Corresponding author

Correspondence to Sarah K. Calabrese.

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Conflict of interest

SKC, KHM, and DSK have received compensation for their efforts in developing and/or delivering medical education related to PrEP. SKC received partial financial support from Gilead Sciences to attend a research conference. KHM has conducted research with unrestricted project support from Gilead Sciences, Merck, and ViiV Healthcare. DSK has been a consultant to Fenway Health for research studies funded by Gilead Sciences and has a pending grant with unrestricted project support from Merck. The authors have no other relevant financial or non-fianical interests to disclose.

Ethical Approval

All study procedures were approved by the Yale University Human Subjects Committee (IRB #HSC-1308012487) and the George Washington University Office of Human Research (IRB #061636) prior to implementation. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Consent to Participate

Online informed consent to participate was obtained from all study participants.

Consent for Publication

Participants were informed of the authors’ intention to publish the results from the study as part of the online consent process.

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Calabrese, S.K., Kalwicz, D.A., Modrakovic, D. et al. An Experimental Study of the Effects of Patient Race, Sexual Orientation, and Injection Drug Use on Providers’ PrEP-Related Clinical Judgments. AIDS Behav 26, 1393–1421 (2022). https://doi.org/10.1007/s10461-021-03495-3

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