AIDS and Behavior

, Volume 22, Issue 4, pp 1122–1138 | Cite as

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
Original Paper


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.


HIV Pre-exposure prophylaxis African Americans Sexual minorities Prejudice Clinical decision-making 



The authors wish to thank the medical students who generously contributed their time and effort by participating in this study. We are also grateful to the medical faculty and student liaisons at participating institutions who supported our recruitment efforts.


Funding and resources for this research were provided by the National Institute of Mental Health (NIMH) via Award Number K01-MH103080 (SKC). The efforts of SKC, DSK, and KU were supported by the NIMH via Award Numbers K01-MH103080 (SKC), K23-MH098795 (DSK), and K01-MH093273 (KU), and the efforts of VAE were supported by the Agency for Healthcare Research and Quality (AHRQ) via Award Number K12-HS022986. Additional support was provided through the District of Columbia Center for AIDS Research (P30-AI117870), the Yale University Center for Interdisciplinary Research on AIDS (P30-MH062294), and the Harvard University Center for AIDS Research (P30-AI060354), all funded by the National Institutes of Health. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH, AHRQ, or NIH.

Compliance with Ethical Standards

Conflicts of interest

SKC, DSK, and KHM have received compensation for their efforts in developing and/or delivering medical education related to PrEP. DSK and KHM have conducted research with unrestricted project support from Gilead Sciences and KHM has conducted research with unrestricted project support from Merck and ViiV Healthcare. KHM is a senior member of the faculty and advisory board of the National LGBT Health Education Center and an associate editor and contributor to educational materials provided through the organization’s website, to which readers of this article are referred. DSK and SKC have contributed to these educational materials as well. The authors declare that they have no other conflicts of interest to disclose.

Research Involving Human and Animal Rights

All procedures performed in this study, which involved human participants, were in accordance with the ethical standards of Yale University’s institutional review board (IRB). IRB approval was obtained prior to study inception. This study did not involve non-human animals.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

10461_2017_1979_MOESM1_ESM.docx (1.2 mb)
Supplementary material 1 (DOCX 1255 kb)
10461_2017_1979_MOESM2_ESM.docx (1.5 mb)
Supplementary material 2 (DOCX 1533 kb)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2017

Authors and Affiliations

  • Sarah K. Calabrese
    • 1
    • 2
  • Valerie A. Earnshaw
    • 3
  • Douglas S. Krakower
    • 4
    • 5
  • Kristen Underhill
    • 6
  • Wilson Vincent
    • 7
  • Manya Magnus
    • 8
  • Nathan B. Hansen
    • 9
  • Trace S. Kershaw
    • 2
  • Kenneth H. Mayer
    • 4
    • 5
  • Joseph R. Betancourt
    • 10
  • John F. Dovidio
    • 2
    • 11
  1. 1.Department of PsychologyGeorge Washington UniversityWashingtonUSA
  2. 2.Department of Chronic Disease EpidemiologyYale School of Public HealthNew HavenUSA
  3. 3.Department of Human Development and Family StudiesUniversity of DelawareNewarkUSA
  4. 4.The Fenway Institute, Fenway HealthBostonUSA
  5. 5.Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  6. 6.Columbia Law SchoolNew YorkUSA
  7. 7.Department of Medicine, Center for AIDS Prevention StudiesUniversity of California, San Francisco (UCSF)San FranciscoUSA
  8. 8.Department of Epidemiology and Biostatistics, Milken Institute School of Public HealthGeorge Washington UniversityWashingtonUSA
  9. 9.Department of Health Promotion and Behavior, College of Public HealthUniversity of GeorgiaAthensUSA
  10. 10.Disparities Solutions Center, Massachusetts General HospitalHarvard Medical SchoolBostonUSA
  11. 11.Department of PsychologyYale UniversityNew HavenUSA

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