Effects of knowledge and implicit biases on pharmacy students' decision-making regarding pre-exposure prophylaxis for HIV prevention: A vignette-based experimental study.

INTRODUCTION: Men who have sex with men (MSM), especially Black MSM, are disproportionately affected by HIV and experience disparate prescription of pre-exposure prophylaxis (PrEP) for HIV prevention compared to White MSM. While pharmacists are essential in efforts to scale-up PrEP, little is known about the role of knowledge and implicit biases in pharmacy students' decision-making regarding PrEP, which may elucidate mechanisms for improving PrEP access and addressing disparities. METHODS: A nationwide, cross-sectional study of pharmacy students in the United States was conducted. A fictional White or Black MSM seeking PrEP was presented. Participants completed measures of PrEP/HIV knowledge, implicit racism and heterosexism, assumptions about the patient's behavior (condomless sex, extra-relational sex, adherence to PrEP), and confidence providing PrEP-related care. RESULTS: A total of 194 pharmacy students completed the study. Compared to the White patient, the Black patient was assumed to be less adherent to PrEP if prescribed. In contrast, assumptions of sexual risk behaviors if prescribed PrEP and confidence providing PrEP-related care did not differ. Additionally, implicit racism was associated with lower confidence providing PrEP-related care, whereas PrEP/HIV knowledge, implicit sexual orientation bias, and assumed sexual risk behaviors if prescribed PrEP were not associated with confidence. CONCLUSIONS: Pharmacists are essential in efforts to scale-up PrEP prescription, making pharmacy education about PrEP for HIV prevention critical. These findings suggest that implicit bias awareness training is needed. This training may reduce the influence of implicit racial bias on confidence providing PrEP-related care and improve knowledge of HIV and PrEP.

Knowledge of human papillomavirus vaccination: A multi-institution, cross-sectional study of allopathic and osteopathic medical students.

Human papillomavirus (HPV) vaccination is a well-established and successful tool for preventing HPV-related cancers. However, vaccine uptake remains low, influenced by patient hesitancy around safety concerns and little opportunity to discuss the vaccine with trusted healthcare providers. We conducted a national, cross-sectional study of allopathic and osteopathic medical students regarding knowledge of HPV vaccination guidelines March-April 2021. Analysis sought to identify gaps in knowledge as well as demographic and academic correlates of knowledge. A total of 718 students participated (response rate = 50.8%). While 92.8% of participants identified the connection between HPV and cervical cancer, lower percentages associated HPV with vaginal/vulvar (67.7%), anal (63.3%), and penile (53.9%) cancers. Low percentages of participants correctly identified age of HPV vaccine eligibility (33.3%) and how many doses are needed for full protection (48.1%). This study identifies specific knowledge gaps in medical students' training on HPV-related cancers and HPV vaccination guidelines. Through addressing these gaps, we may improve HPV vaccine uptake and decrease the incidence of HPV-related cancers.

The Role of Social Biases, Race, and Condom Use in Willingness to Prescribe HIV Pre-exposure Prophylaxis to MSM: An Experimental, Vignette-Based Study.

INTRODUCTION: Daily antiretroviral pre-exposure prophylaxis (PrEP) is a safe and effective method of preventing HIV. Clinicians' assumptions, biases, and judgments may impede access to PrEP. Specifically, concern that patients will engage in more condomless sex ("risk compensation") has been cited by clinicians as a reason for not prescribing PrEP. METHODS: In this experimental study among medical students, we systematically varied race (White or Black) and condom-use behaviors (continued-use, planned-discontinuation, or continued-nonuse) of a fictional patient (all men with multiple male sex partners). Participants indicated the patients' assumed adherence to PrEP, patients' overall HIV risk, and willingness to prescribe PrEP. Participants completed an implicit association test to detect implicit racism and measures of heterosexism and attitudes toward nonmonogamy, which were examined as moderators of patient race and condom-use effects on participants' assumptions and ultimate willingness to prescribe PrEP. RESULTS: Participants ( N = 600) were most willing to prescribe PrEP to the continued-nonuse patient and least willing to prescribe to the planned-discontinuation patient. No differences were identified based on patient race. The continued-nonuse (vs. continued-use) patient was perceived as less likely to adhere to PrEP, which was associated with lower willingness to prescribe. Negative attitudes toward nonmonogamy exacerbated this effect. No effects of implicit racism or explicit heterosexism were identified. CONCLUSIONS: Participants were least willing to prescribe PrEP to patients who planned to discontinue condom use. Patients seeking PrEP are exhibiting agency over their sexual health, and clinicians should fulfill their role in ensuring access to this primary preventative therapy. Training and curricular reform regarding PrEP are needed.

Assumptions about patients seeking PrEP: Exploring the effects of patient and sexual partner race and gender identity and the moderating role of implicit racism.

INTRODUCTION: Daily pre-exposure prophylaxis (PrEP) for HIV-prevention is an essential component of national plans to end the HIV epidemic. Despite its well-documented safety and effectiveness, PrEP prescription has not met the public health need. Significant disparities between White and Black people exist with respect to PrEP prescription, as do disparities between men and women. One factor contributing to these disparities is clinicians' assumptions about patients seeking PrEP. METHODS: The present study sought to investigate medical students' assumptions about patients seeking PrEP (anticipated increased condomless sex, extra-relational sex, and adherence to PrEP), and assumed HIV risk when presenting with their sexual partner. We systematically varied the race (Black or White) and gender (man or woman) of a fictional patient and their sexual partner. All were in serodifferent relationships including men who have sex with men (MSM), women (MSW), and women who have sex with men (WSM). Participants also completed an implicit association test measuring implicit racism against Black people. We evaluated the moderation effects of patient and partner race on assumptions as well as the moderated moderation effects of implicit racism. RESULTS: A total of 1,472 students participated. For MSM patients, having a Black partner was associated with higher assumed patient non-adherence to PrEP compared to a White partner, however a White partner was associated with higher assumed HIV risk. For MSW patients, a White male patient was viewed as being more likely to engage in more extra-relational sex compared to a Black male patient. For WSM patients, White women were assumed to be more likely to have condomless and extra-relational sex, be nonadherent to PrEP, and were at higher HIV risk. Overall, implicit racism was not related to negative assumptions about Black patients as compared to White patients based on patient/partner race. DISCUSSION: Medical education about PrEP for HIV prevention must ensure future health professionals understand the full range of patients who are at risk for HIV, as well as how implicit racial biases may affect assumptions about patients in serodifferent couples seeking PrEP for HIV prevention. As gatekeepers for PrEP prescription, clinicians' assumptions about patients seeking PrEP represent a barrier to access. Consistent with prior research, we identified minimal effects of race and implicit racism in an experimental setting.

Willingness to Prescribe PrEP to Bisexual Men Depends on Genders of Their Past Partners: A Study of Medical Students in the USA.

Bisexual men are at increased risk for HIV compared to heterosexual men but unlikely to use pre-exposure prophylaxis (PrEP). Given that biases may influence whether bisexual men are prescribed PrEP, we examined whether medical students' decision-making was influenced by the genders of a bisexual male patient's partners. Medical students (N = 718) were randomized to one of nine conditions where they answered questions about a bisexual male patient after reviewing his electronic medical record. We manipulated the gender of his current partner (none, male, female) and the genders of his past partners (male, female, both). Current partners were described as living with HIV and not yet virally suppressed, past partners were described as being of unknown HIV-status, and condom use was described as intermittent with all partners. When the patient was not in a current relationship, perceived HIV risk and likelihood of prescribing PrEP were lowest if he only had female partners in the past. When he was in a current relationship, perceived HIV risk and likelihood of prescribing PrEP did not differ based on current or past partners' genders. In addition, identification as a PrEP candidate, perceived likelihood of adherence, and perceived likelihood of engaging in condomless sex if prescribed were lower when the patient was not in a current relationship. Medical students appropriately prioritized the status of the partner living with HIV, but their decision-making was influenced by past partner genders when the patient was not in a current relationship. Medical students may require additional education to ensure they understand PrEP eligibility criteria and make decisions based on patients' individual presentations.

Evaluating Medical Students' Views of the Complexity of Sexual Minority Patients and Implications for Care.

Purpose: Sexual and gender minority (SGM) people experience many health care disparities. We aimed to determine if medical students viewed sexual minority patients (lesbian, gay, or bisexual [LGB] men/women) as more complex than heterosexual patients, even when presenting with the same symptoms, and whether this perceived complexity affected confidence caring for LGB patients. Methods: A fictional patient with an upper respiratory infection was presented with systematic variation of the patient's sexual orientation across six experimental conditions in an online, vignette-based experimental study. Participants rated their perception of the medical, therapeutic, and social complexity of the patient, and completed a measure of stigma toward SGM people. Finally, participants indicated their confidence caring for the presented patient. Results: Overall, 665 students participated. Participants viewed the LGB patients as more complex across all domains, relative to heterosexual patients. Perceived medical and social complexity predicted lower confidence caring for the patient. Participants reported lower confidence caring for gay male patients with indirect effects of medical and social complexity. LGB identity was broadly and indirectly associated with lower confidence through social complexity. Conclusion: Our results suggest students view LGB patients as more complex compared with heterosexual patients. Medical education programs must provide training about the effects of social biases on clinical judgments and care for LGB patients, as well as build skills to ensure confidence caring for LGB patients.

Where Do Health Professions Students Learn About Pre-exposure Prophylaxis (PrEP) for HIV Prevention?

HIV pre-exposure prophylaxis (PrEP) is critical for ending the HIV epidemic, and a necessary part of health professions education. We present data from a US survey study (N = 2085) about educational experiences (coursework and extracurricular), in which medical, physician assistant, nursing, and pharmacy students received training about HIV risk factors and PrEP. We found a discrepancy between the percentage of courses covering HIV risk factors (84.7%) compared to PrEP (54.6%) for all students (P < .001), and specifically among final-year students (92.0% vs. 59.7%; P < .001). Pharmacology courses were the most common exposure to PrEP (46.0%), and 61.3% of students were introduced to PrEP through an extracurricular experience. Health professions education must present HIV risk factors in conjunction with PrEP. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01265-3.

Effects of Patient Sexual Orientation and Gender Identity on Medical Students' Decision Making Regarding Preexposure Prophylaxis for Human Immunodeficiency Virus Prevention: A Vignette-Based Study.

INTRODUCTION: Preexposure prophylaxis (PrEP) is a pillar of our national strategy to end the human immunodeficiency virus (HIV) epidemic. However, one of the largest obstacles to realizing the effectiveness of PrEP is expansion of prescription to all patients at risk for HIV. In this vignette-based study, we sought to investigate medical students' decision making regarding PrEP by presenting fictional patients, all of whom had HIV risk factors based on sexual behavior. METHODS: We systematically varied patients' sexual orientation or gender identity (heterosexual female, gay male, bisexual male, transgender male, transgender female, gender nonbinary person). We assessed the medical students' willingness to prescribe PrEP to the patients, as well as their perceptions of the patients' HIV risk and behavior. RESULTS: A total of 670 US medical students completed the study. The heterosexual female patient was least frequently identified as a PrEP candidate, was viewed as least likely to adhere to PrEP, and the most likely to engage in condomless sex if prescribed PrEP; however, was considered at lower overall HIV risk. Lower perceived HIV risk and anticipated PrEP adherence were both associated with lower willingness to prescribe PrEP. Willingness to prescribe PrEP was highest for the gay male patient and lowest for the heterosexual female. CONCLUSIONS: These analyses suggest that assumptions about epidemiological risk based on patients' gender identity or sexual orientation may reduce willingness to prescribe PrEP to heterosexual women, ultimately hindering uptake in this critical population.

Knowledge of HIV and HIV pre-exposure prophylaxis among medical and pharmacy students: A national, multi-site, cross-sectional study.

Pre-exposure prophylaxis (PrEP) is a highly effective strategy for preventing HIV. However, prescription of PrEP has not reached the scale that is necessary to meet the public health need of reducing HIV incidence. A factor contributing to this slow scale-up is limited healthcare practitioners' knowledge of PrEP, making PrEP education a priority. We conducted a national, cross-sectional study of medical (allopathic and osteopathic) and pharmacy students regarding knowledge of PrEP and HIV between October 2020 and February 2021. We included 28 items in our knowledge assessment. Analysis sought to identify gaps in knowledge as well as academic and demographic correlates of knowledge. A total of 2,353 students participated in the study (response rate = 17.0%). The overall mean HIV knowledge score was 79.6% correct. Regarding specific items, 68.7% of participants believed HIV treatment was difficult because it required many pills, and 61.1% incorrectly indicated a person with an undetectable HIV viral load could transmit the virus to their sexual partners. Overall mean PrEP knowledge was 84.1%. Approximately one-third of participants did not identify HIV-negative status as a requirement to be a PrEP candidate. Gay/lesbian participants and those who were in the late-phase of training reported higher knowledge of both HIV and PrEP than did heterosexual participants and those in the early-phase of training. This study identifies specific gaps in training on HIV prevention with PrEP that must be improved in health professions education to ensure PrEP reaches its full potential in ending the HIV epidemic.

Health Profession Students' Awareness, Knowledge, and Confidence Regarding Preexposure Prophylaxis: Results of a National, Multidisciplinary Survey.

BACKGROUND: Preexposure prophylaxis (PrEP) is a highly effective, pharmacologic method of HIV prevention. Despite its safety and efficacy, PrEP prescription remains low in those patients who are at highest risk for HIV infection. One possible reason for this may be the lack of inclusion of PrEP and HIV prevention discussions within the curricula of health professions education. METHODS: An online survey was administered to a cross-sectional sample of future prescribers (osteopathic/allopathic medical and physician assistant students), future nurses, and future pharmacists (n = 2085) in the United States between January and July 2019 to assess and compare awareness of PrEP, PrEP education, PrEP knowledge, and confidence in 2 areas related to PrEP. RESULTS: We show that, overall, awareness of PrEP is high among future health care providers (81.6%), with the future pharmacists reporting the greatest awareness (92.2%; P < 0.001) and more commonly reporting PrEP education (71.0%). Students had mixed knowledge of PrEP, with future pharmacists reporting the highest knowledge of PrEP. Approximately 30% of students in all disciplines reported having low confidence counseling a patient about PrEP and low confidence educating a colleague about PrEP. Knowledge of PrEP was a significant predictor of confidence counseling a patient about PrEP (P < 0.001) and educating a colleague about PrEP (P < 0.001). CONCLUSIONS: This study identifies opportunities to improve and incorporate evidence-based strategies for educating future health care providers about PrEP for HIV prevention within health professions curricula.

A National Study of Medical Students' Attitudes Toward Sexual and Gender Minority Populations: Evaluating the Effects of Demographics and Training.

Purpose: Evaluating medical students' attitudes toward sexual and gender minority (SGM) people is important to identify negative attitudes early in education and to design curriculum to mitigate biases. The purpose of this study was to investigate medical students' attitudes toward SGM people as a whole as well as specific populations within the SGM community. We sought to determine whether attitudes toward SGM people differed between students' demographics and training. Methods: We conducted an online survey-based study among 1007 medical students at 12 U.S. medical schools. Participants completed the Attitudes Toward LGBT People Scale and were randomized to complete another scale specific to one group within the SGM community. We evaluated the association between student demographics and medical training and attitudes toward SGM people overall and toward specific SGM populations. This study was conducted between January and June 2020. Results: Overall, we found that medical students had positive attitudes toward SGM people and specific SGM groups. The most important factor affecting medical students' attitudes on all scales was religiosity, as very religious students held less positive attitudes toward SGM people. In addition, cisgender female students held more positive attitudes toward SGM people overall and toward specific SGM populations. Conclusion: Medical education must ensure that future physicians receive comprehensive and culturally competent training to prepare them to care for SGM patients. Based on our findings, this training should include specific content to help medical students identify potential biases toward SGM people, as well as strategies to acknowledge and confront these biases.

Student Education About Pre-exposure Prophylaxis (PrEP) Varies Between Regions of the United States.

BACKGROUND: Daily, oral pre-exposure prophylaxis (PrEP) is an effective and safe prevention strategy for people at risk for HIV. However, prescription of PrEP has been limited for patients at the highest risk. Disparities in PrEP prescription are pronounced among racial and gender minority patients. A significant body of literature indicates that practicing healthcare providers have little awareness and knowledge of PrEP. Very little work has investigated the education about PrEP among health professionals in training. OBJECTIVE: The objective of this study was to compare health professions students' awareness of PrEP and education about PrEP between regions of the US, and to determine if correlations between regional HIV incidence and PrEP use were present. DESIGN: Survey study. PARTICIPANTS: A cross-sectional sample of health professions students (N = 1859) representing future prescribers (MD, DO, PA), pharmacists, and nurses in the US. KEY RESULTS: Overall, 83.4% of students were aware of PrEP, but only 62.2% of fourth-year students indicated they had been taught about PrEP at any time during their training. Education about PrEP was most comprehensive in the Northeastern US, the area with the highest PrEP to need ratio (4.7). In all regions, transgender patients and heterosexual men and women were least likely to be presented in education as PrEP candidates, and men who have sex with men were the most frequently presented. CONCLUSIONS: There are marked differences in education regarding PrEP both between academic programs and regions of the USA.

Effect of extracellular glucose and K+ on intracellular osmolytes and volume in a human kidney cell line.

The goal of this study was to assess the effect of extracellular glucose and K+ ((K)o) on the intracellular osmolyte content and cell volume maintenance and regulation in a human embryonic kidney cell line (tsA201a). Cell volume maintenance was studied by isotonic (313 +/- 5 mOsm) replacement of culture media by a glucose-free Ringer solution containing (in mM) 0, 3, 6, or 10 K+. Cell volume regulation was studied by exposing cells to hypotonic (250 +/- 5 mOsm) glucose-free Ringer solution containing the various (K)o. The results showed that: 1) intracellular osomlyte content (i.e. Na+, Cl-, Urea and free amino acids (FAA)) and cell volume increased when culture media was replaced with isotonic Ringer at all (K)o; 2) osmolyte content decreased with continuous exposure to isotonic Ringer at all (K)o but cell volume changes depended on (K)o. Volume recovery occurred at 6 and 10 mM K+; 3) exposure to hypotonic Ringer induced swelling at all (K)o followed by a reduction in measured intracellular osmolytes. Regulatory volume decrease occurred in 6 or 10 mM K+ but swelling continued in 0 or 3 mM K+; and 4) addition of ouabain produced swelling without recovery under iso- and hypotonic conditions. These results indicate that the removal of extracellular glucose produced a transient inhibition of the Na+/K+ ATPase resulting in a transient increase in the intracellular content of Urea, FAA and cell volume and (K)o regulated an as yet unidentified intracellular osmolyte.