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Better patient-provider communication may improve PrEP access for MSM
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Men who have sex with men reported that barriers to establishing nonjudgmental relationships with primary care providers limited their access to pre-exposure prophylaxis for the prevention of HIV infection, according to new research published in LGBT Health.
“Despite recent emphasis on the importance of creating a clinical atmosphere conducive to disclosing sexual orientation, taking a sexual history, and assessing HIV risk, this study suggests that primary care providers’ failure to do so remains a barrier to HIV prevention,” William M. Byne, MD, PhD, associate professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York City, and editor-in-chief of LGBT Health, said in a press release.
These findings led Kevin M. Maloney, MPH, of the division of infectious diseases at Beth Israel Deaconess Medical Center, and colleagues to call for improved communication about sexual behaviors between patients and providers to increase the use of pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM), which has been shown to reduce HIV incidence in this population by 86% to 99% in clinical trials.
“We designed this study to understand MSM patient preferences for discussing PrEP and HIV risk reduction with their medical providers,” Maloney told Infectious Disease News. “During our focus group conversations, many of the men expressed a reluctance to be fully honest with their provider, due to past experiences of intolerance and discrimination in health care settings or simply an expectation of being stigmatized for their sexual behaviors. This underscores the importance of establishing a nonjudgmental environment for patients to disclose sensitive information and to be proactive in initiating the conversation in the first place.”
Previous research has shown that less than half of MSM disclose their sexual orientation to primary care providers (PCPs), whereas 45% report they are uncomfortable discussing their sexual behavior with PCPs and only 39% report they have ever discussed HIV prevention with PCPs. Therefore, to better understand how stigma experienced by MSM in health care settings may limit their access to PrEP, Maloney and colleagues conducted two online focus groups involving MSM from many different regions in the United States. They recruited participants from a sexual networking website, and offered a $75 incentive to participate.
Overall, 88 interested participants met eligibility criteria, which included being aged 18 years or older, being assigned male sex at birth, being HIV negative by self-report, and reporting having condomless anal sex with at least one casual partner or a main sexual partner who is HIV positive within the past 3 months. A total of 24 individuals, mostly identifying as gay and single, ultimately participated in one of the two online focus groups (median age, 48 years; 87% white).
The investigators noted that none of the participants had previously used PrEP, few had heard of it and knowledge was limited among most who had. Most said health care providers would be their preferred source for additional information on PrEP, and many said a PCP would be the ideal health care provider for these discussions.
However, just one participant had discussed PrEP with a health care provider, and most said they would be uncomfortable discussing PrEP with their PCP because of embarrassment or fear of being judged. These participants “viewed this limitation as a major barrier to discussing sexual health, HIV prevention, and PrEP,” and for some, “nondisclosure of sexual behavior was a consequence of PCPs failing to take complete sexual health histories, whereas other participants directly avoided answering questions,” investigators wrote.
They noted that the small, older and mostly white cohort limits the extrapolation of these findings to young, minority MSM, and although the findings suggest stigma can affect MSM from diverse geographical regions, those “outside major metropolitan regions may have greater difficulty finding and establishing an acceptable relationship with a PCP.”
Maloney and colleagues concluded that “interventions are needed to train PCPs to conduct culturally competent discussions regarding sexual health and HIV prevention, identify PrEP candidates, and establish trusting relationships with patients that might facilitate disclosure of sexual orientation and HIV risk behaviors. Point-of-care tools for clinicians, such as culturally tailored HIV risk screeners, could facilitate these conversations for PCPs with less experience with MSM.”
Training resources are available at www.lgbthealtheducation.org, and provider location tools are available at www.PrEPlocator.org and www.AIDSvu.org. – by Adam Leitenberger
Disclosures: The authors report no relevant financial disclosures.
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