Condoms and the Double Standard in Prescribing PrEP

Could a provider's personal bias and beliefs about condom use affect their willingness to prescribe PrEP (pre-exposure prophylaxis)? One study surveyed U.S. medical students and found bias in terms of willingness to offer PrEP based on clinical situations. The students who were surveyed seemed to be most willing to provide PrEP to the lowest-risk consumers. And the team uncovered what looked like heteronormative biases on what was conceptualized as "acceptable reasons for non-condom use." Terri Wilder, M.S.W., spoke with study author Sarah Calabrese, Ph.D., at HIVR4P (HIV Research for Prevention) 2016, in Chicago.

Terri Wilder: I'm here today with Sarah Calabrese, Ph.D., who is an assistant professor of clinical psychology at George Washington University. Sarah, welcome.

Sarah Calabrese: Thank you. It's wonderful to be here. I appreciate this opportunity.

TW: Could you tell our readers a little bit about why you wanted to do this survey, what was your motivation, and then just tell us a little bit about the methods?

SC: Yeah, absolutely. As you know, PrEP is a really important new prevention tool. It's very effective. It's been available since 2012. Despite the fact that it works so well and it's been available for over four years, a lot of providers aren't prescribing it. To the extent that PrEP is a prescription-based medication, we're really reliant on providers. They are essentially the gatekeepers when it comes to PrEP access.

Some of my other work has been looking at barriers to prescribing, and one of the ones that comes up in my work and in others is this issue of sexual risk compensation. When I say "risk compensation," I'm talking about providers being concerned that if they prescribe PrEP to their patients, the patients will essentially increase their sexual risk-taking in response to a perceived decrease in susceptibility to HIV.

In other words, the providers think that if they give them this pill, then the patients will abandon condoms, or have more sexual partners, etc. Providers see this as a problem.

My colleagues and I were interested in what happens to the patient who says that he plans to abandon condom use, or what happens to the patient who says he's not using condoms in the first place. What does that mean for prescription decision-making around PrEP?

We surveyed 111 medical students from two universities in the Northeast, and we gave them some background about PrEP. About half of them said they had already learned about PrEP as part of their medical education, but we wanted to make sure that everyone had at least the basic background. As part of the background, we told them about the efficacy of PrEP. We told them that it was U.S. Food and Drug Administration approved. Then we asked them to indicate their willingness to prescribe.

So, there are two parts to this, one being their willingness to prescribe to a variety of different patients. With these different patients they were rating their prescription willingness for, we systematically varied the condom use and intentions of these patients, as well as what kind of relationship they were in -- whether they were in a monogamous relationship or a non-monogamous relationship.

In this piece of the project, essentially the take-home, and what you spoke to, was that the students were by far more willing to prescribe to the patient who said that he was a condom user and planned to continue using condoms. They were much less willing to prescribe to the patient who didn't use condoms and wasn't going to start using condoms -- and even less willing to prescribe to the patient who used condoms and wanted to stop using condoms. That was consistent, whether the patient we described was a man who was in a monogamous relationship with an HIV-positive, untreated man -- meaning, somebody who was at very high risk of HIV -- or a man who had multiple male sexual partners of unknown HIV status. In both of these different relationship contexts, the men were at very high risk and would be prime PrEP candidates.

We saw a similar pattern. But we also saw that students seemed to be more willing to prescribe to the man who was in a monogamous relationship for two out of the three different condom profiles. That was the first piece.

The second piece, which you also mentioned, was that we asked them to indicate the acceptability of different reasons for discontinuing condoms with PrEP. And, you know, when it comes to acceptability, if they were basing this on clinical judgment everything should be equally as acceptable because it would confer the same level of risk. If you're discontinuing condoms, that's the same risk. And yet, what we found was that many more were accepting of a patient discontinuing PrEP for the sake of conception versus any other reason. And the other reasons that we offered were physical pleasure, emotional intimacy or physical functioning (that is, erectile difficulty).

As you said, it seemed as if there was this heteronormative bias -- the fact that the one reason that a gay man would not discontinue condoms, at least with a male partner, is conception. And yet, that's the one that they were most accepting of. That's what I felt maybe inferred a bit of heterosexism.

The take-home I think, just from the research, is just that medical students' prescribing intentions or willingness were completely misaligned, paradoxical to patients' actual risk, and they were much more accepting of conception over other reasons.

TW: Your study looked at medical students who may be, to varying degrees, about to graduate and be out in the real world, as it were, starting to practice. So, that's one cohort of people. I wonder about the people who are already practicing. Is this microcosm of maybe what's happening with people who are practicing, who may not necessarily be HIV providers that have already drunk the Kool-Aid for PrEP? And, thinking about people who are family physicians or OBGYN, who may be a gateway to PrEP and concerned about uptake with PrEP, is this a potential barrier that we're not really addressing?

SC: Right. The research itself only speaks to medical students, so I guess anything beyond that would be speculation. But I would say that this is a potential issue for providers, practicing providers. I think that the message that we give to providers about how condoms fit into the picture with PrEP is a little bit murky, and I think it leaves room for personal biases to enter.

A lot of the PrEP education, or even the PrEP guidelines, they don't specifically address: OK, well, so the patient doesn't want to use condoms or starts using condoms and wants to stop using condoms. It's not very clear what the protocol is. So, I think we need to be clear with providers when offering guidelines or when doing the training, to ensure that they recognize that, certainly, you want to encourage concomitant use of PrEP and condoms. Certainly, PrEP does not protect against other sexually transmitted infections (STIs) and pregnancy. That's something you want to make sure the patient realizes.

You also want to support the patient in making his or her own decisions. I'm a big advocate of the patient-centered approach, where the role of the provider is to help the patient make informed decisions. I think that's really what we need to emphasize, both in the guidelines and in the trainings that we do.

TW: In terms of medical student education, your conclusions from the survey: What would be something that you could recommend to medical schools, in terms of curricula about PrEP?

SC: Yeah. One of the things that I've talked about in my other work is including cultural competence and thinking about issues of bias, particularly for the populations most at risk for HIV or most affected by HIV. Those are often stigmatized groups, whether it's gay men, whether it's racial minorities, racial minority gay men, sex workers. There are groups that face stereotypes and stigma in our society.

When educating about PrEP it's really important to address issues of bias related to race and related to sexual orientation, etc. But what this study got me thinking about is that it's also important, when talking about bias, to raise this issue. There's a window there for personal values to interfere with clinical judgment -- and actually, this shouldn't just be medical education for students. At any level, I think that we really need to be talking about how personal values can also bias clinical decision-making -- personal values about condoms, personal values about monogamy, in addition to all of these other sorts of isms: racism, sexism, heterosexism.

TW: Well, it's interesting. I think in your presentation you talked about how we don't withhold other treatment from certain illnesses or conditions. So why are we doing this for PrEP? There are people who have spoken publicly that withholding PrEP from a patient is malpractice.

SC: Yeah, I would say that I am in that camp. It seems that PrEP is becoming, more and more, sort of a standard of care. And to withhold it -- I mean, what is the reason for withholding it? To withhold it because of concerns about other STIs -- that doesn't really make sense. That's an argument people use, but the reality is that other STIs, by and large, are curable or manageable. They're not the same severity as HIV. The way that the PrEP follow-up protocol is designed; anyone who's getting STIs has the option. They're getting tested routinely, so it can be immediately diagnosed, and it can be immediately treated.

Yes, PrEP patients -- of course they're at risk for STIs. They wouldn't be taking PrEP if they didn't think they were at risk. So, it's not surprising that PrEP users are going to be at risk of STIs and may get STIs. But, I think we have to keep it in perspective when we're thinking about that.

So, apart from the STI argument, I don't really understand what would be a reasonable explanation for withholding PrEP. I really don't. As you say, I had brought up in my presentation that we don't do this with other forms of prevention.

We don't do this with birth control. The reality is, if a woman wants birth control, say she goes into her doctor. First of all, I think a lot of doctors don't ask these questions to begin with. But even if she told her doctor that she was going to stop using condoms, I don't think the doctor would blink. I think maybe the doctor would say, "Well, just so you know, you're still at risk for STIs."

But I think a lot of doctors accept and even expect a woman to stop using condoms when she starts birth control. This feels like unnecessary exceptionalism. This feels like a double standard applied to PrEP.

TW: In terms of the study, are there any additional studies that you're going to do to explore this stuff a little bit more? I'm curious whether you're going to do any kind of qualitative studies to try to have some interviews with some of the medical students.

SC: I was talking about this with colleagues. I wish that we had put in our IRB protocol: Can we reach out and follow up? Because I want to be asking those questions.

I can tell you that we don't have anything immediately planned in terms of doing qualitative work on this, in particular. But I do have a national survey of physicians currently underway -- these are actively practicing licensed doctors -- to see what biases may be operating in their decision-making around prescribing PrEP. That's a quantitative survey.

But, yeah. I would say we're in very preliminary stages of thinking about next steps. But I agree that a qualitative piece would be really interesting.

TW: It would also be interesting to look past medical doctors, to nurse practitioners, physician assistants.

SC: Absolutely.

TW: They write prescriptions, as well.

SC: You're absolutely right about that. And I think that those other groups are going to be essential for providing PrEP. Absolutely. Part of what I do, in addition to research, is also training around PrEP. Our audience: some of them are physicians or M.D.s, but there's also PAs and NPs. I think it's important to be addressing that audience.

So, yeah. I agree with you. Actually, the provider survey I mentioned that's a national survey of physicians, we're actually looking now to open it up to a broader circle of prescribers.

TW: Great. Well, thank you so much for talking to us today.

SC: Thank you.

If you have questions or comments about the study, you can contact Sarah Calabrese, Ph.D., at

This transcript has been lightly edited for clarity.