Many Providers Are Biased Against Prescribing PrEP to People Who Inject Drugs

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Health care providers are less likely to prescribe pre-exposure prophylaxis (PrEP) for people who inject drugs (PWID) because of strongly held beliefs that PWID are irresponsible and won't adhere to their medication, according to data presented at the 2019 National HIV Prevention Conference (NHPC).

Sarah Calabrese, Ph.D., assistant professor of clinical psychology at George Washington University, was inspired to launch this National Institutes of Health-funded study because her prior qualitative research sparked a question about providers' misplaced assumptions about PWID.

Calabrese reported that during her qualitative research, one clinician told her, "They're not good PrEP candidates 'cause they're not reliable in any way." This idea persists, despite multiple studies demonstrating high levels of PrEP adherence in this group.

The stereotype of poor adherence among PWID also exists despite the CDC's recommendation to prescribe PrEP for people who inject drugs.

To explore provider bias, Calabrese and her colleagues designed a survey-based study that examined two potential areas of bias: risk behavior and race. To capture HIV risk behavior, Calabrese designed six fictional patients representing three different risk factors -- a man who shares needles with an HIV-positive injecting partner, a man who has insertive anal sex with an HIV-positive man, and a man who has insertive vaginal sex with an HIV-positive woman. In each scenario, the HIV-positive partner was not on treatment.

To examine racial bias, the survey designated the fictional patients as either black or white, indicating race with a checkbox on their medical form and by stylizing the patients' names as those traditionally associated with a particular race (for example, "Greg" for a white man and "Jermaine" for a black man.)

Of the 293 providers who responded to the survey, the majority were white (76%), heterosexual (74%), and practicing in an urban setting (76%). Most of the providers self-identified as HIV specialists (66%), and the majority said they had cared for patients at high risk for HIV in the past.

Providers were asked a series of questions designed to gauge their likelihood of prescribing PrEP to the six different fictional patient profiles.

Perhaps surprisingly, "Patient race had minimal impact on clinical decision-making," said Calabrese. It's possible that race didn't impact provider decision-making because it is now a well-understood area of potential bias, whereas injection drug use is less frequently discussed in sensitivity trainings and in the media in general as an issue where bias might be present.

"I think that stigma toward people who inject drugs is still pretty pervasive, and somehow it's deemed to be more acceptable" than stigma toward racial minorities, Calabrese said.

Importantly, the fictional patients described in the survey did not all have equal HIV risk. The man who injected drugs had a five times higher HIV acquisition risk than the man who was having penetrative anal sex with another man, and 15 times higher risk than the man who was having penetrative vaginal sex with a woman.

The providers understood this relative risk situation clearly.

"The man who injected drugs was judged to be at higher HIV risk than the MSM [men who have sex with men]," said Calabrese. "However, he was anticipated to be of poorer adherence than the MSM and MSW [men who have sex with women], and less safety conscious than both groups as well."

All of these findings were statistically significant.

Calabrese's presentation rattled the audience members gathered in a small conference room at the Hyatt Regency Atlanta Hotel. As soon as she finished speaking, an audience member shouted out, "How dare them!" in reference to providers' reluctance to prescribe PrEP to PWID.

One of the most egregious findings was the fact that providers had correctly identified that the man who injects drugs was at higher risk and could therefore benefit from PrEP. Despite this understanding, "providers expressed less favorable perceptions of him, and lower willingness to prescribe PrEP for him as compared to other patients," Calabrese said.

Calabrese suggested that the language of the CDC guidance could be a potential factor in the providers' reluctance to prescribe PrEP for PWID.

"We know from research in other health domains that provider biases are [more] likely to affect medical decision-making when those decisions are more discretionary in nature," Calabrese said.