Department of Psychology, George Washington University, Washington, DC, USA.
Social and Behavioral Sciences Department, Yale School of Public Health, Yale University, New Haven, CT, USA.
J Int AIDS Soc. 2018 Jun;21(6):e25147. doi: 10.1002/jia2.25147.
Despite healthcare providers' growing awareness of pre-exposure prophylaxis (PrEP), prescription rates remain low. PrEP is an efficacious HIV prevention strategy recommended for use with condoms but still protective in their absence. Concern about the impact of PrEP on condom use and other risk behaviour is, nonetheless, among the barriers to prescription commonly reported. To understand the implications of this concern for PrEP access, we examined how medical students' willingness to prescribe PrEP varied by patients' condom use and partnering practices. We also assessed the perceived acceptability of various reasons for condom discontinuation with PrEP.
An online survey was distributed to 854 medical students in the Northeastern US in 2015. Participants (n = 111) were surveyed about their willingness to prescribe PrEP for each of six male patients who systematically differed in their reported condom use (sustained use, sustained nonuse, or discontinuation with PrEP) and partnering practices (single male partner with untreated HIV or multiple male partners of unknown HIV status). Participants also reported perceived acceptability of four reasons for condom discontinuation: pleasure, sexual functioning, intimacy, and conception.
Willingness to prescribe PrEP was inconsistent with patient risk: When the patient used condoms and planned to sustain condom use, most participants were willing to prescribe PrEP - 93% if the patient had a single partner and 86% if the patient had multiple partners. Fewer were willing to prescribe if the patient did not use condoms and planned to sustain nonuse (53% and 45%, respectively) or used condoms but planned to discontinue use (27% and 28%). Significantly fewer participants were willing to prescribe for a patient with multiple partners versus a single partner when the patient reported sustained condom use or sustained condom nonuse. The number of participants who were willing to prescribe was similarly low for a patient with multiple partners versus a single partner when the patient reported that he planned to discontinue condom use. More participants accepted a patient discontinuing condoms for conception (69%) than for intimacy (23%), pleasure (14%), or sexual functioning (13%).
Medical students' clinical judgments were misaligned with patient risk and suggest misconceptions or personal values may undermine provision of optimal HIV prevention services.
尽管医疗保健提供者对暴露前预防（PrEP）的认识不断提高，但处方率仍然很低。PrEP 是一种有效的 HIV 预防策略，建议与避孕套一起使用，但在没有避孕套的情况下仍然具有保护作用。然而，对 PrEP 对避孕套使用和其他风险行为的影响的担忧是处方的常见障碍之一。为了了解这种担忧对 PrEP 获得的影响，我们研究了医学生开具 PrEP 处方的意愿如何因患者的避孕套使用和伴侣行为而有所不同。我们还评估了各种因 PrEP 而停止使用避孕套的理由的可接受性。
2015 年，我们向美国东北部的 854 名医学生在线分发了一份调查问卷。参与者（n=111）被调查了他们对每位男性患者开具 PrEP 的意愿，这些患者的报告的避孕套使用情况（持续使用、持续不使用或使用 PrEP 时停止使用）和伴侣行为（有未经治疗的 HIV 的单一男性伴侣或未知 HIV 状态的多个男性伴侣）系统地有所不同。参与者还报告了对以下四种停止使用避孕套的理由的可接受性：愉悦感、性功能、亲密感和怀孕。
开具 PrEP 的意愿与患者的风险不一致：当患者使用避孕套并计划继续使用避孕套时，大多数参与者愿意开具 PrEP-如果患者有单一伴侣，则有 93%的参与者愿意开具 PrEP，如果患者有多个伴侣，则有 86%的参与者愿意开具 PrEP。当患者不使用避孕套并计划继续不使用避孕套时（分别为 53%和 45%），或使用避孕套但计划停止使用避孕套时（分别为 27%和 28%），愿意开具 PrEP 的人数较少。当患者报告持续使用避孕套或持续不使用避孕套时，与单一伴侣相比，报告有多个伴侣的患者愿意开具 PrEP 的人数较少。当患者报告计划停止使用避孕套时，与单一伴侣相比，报告有多个伴侣的患者愿意开具 PrEP 的人数也较少。更多的参与者接受患者因怀孕而停止使用避孕套（69%），而不是因亲密感（23%）、愉悦感（14%）或性功能（13%）而停止使用避孕套。
医学生的临床判断与患者的风险不一致，这表明误解或个人价值观可能会破坏提供最佳 HIV 预防服务。
