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.

Abstract

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. 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. 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. 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.