Cultural Bias Impedes PrEP Education and Access
Now more than ever, preventive health measures are a daily topic of discussion in the United States. Despite this, conversations concerning human immunodeficiency virus (HIV) and pre-exposure prophylaxis (PrEP) are still stagnated, stigmatized and suffocated on educational, medical and state levels.
Why do doctors, who have no problem advocating for improvements in vaccine knowledge and education, still fail patients who are interested in PrEP? Though PrEP is not a vaccine, it is a highly effective method of preventing HIV transmission if someone is exposed to the virus. Many physicians remain grossly undereducated on these facts, and, in some cases, are staunchly unwilling to discuss PrEP as an option for people whose lifestyle includes an increased risk of HIV exposure.
Unfortunately, this quiet opposition to PrEP access and information may be because of systemic ignorance, casual bigotry and errors in legislative oversight.
The cost of capitalism in healthcare
"A big piece in the LGBTQ community—and I would argue across marginalized communities—is cost as a barrier to be able to access this prescription," said Taylor Small, director of health and wellness for Pride Center of Vermont.
"For those who either aren't covered [by insurance] or have subpar coverage, it is beneficial to be able to just pick up your prescription and not have to worry about paying a copay, as well," Small continued, referring to copay cards given to community members interested in PrEP in Vermont.
While Pride Center of Vermont does not access funding from the Ryan White Program, the largest federal program servicing HIV patients, they do work in collaboration with Vermont CARES and the Comprehensive Care Clinics of the University of Vermont Medical Center to ensure that potentially at-risk members of the population have unimpeded access to vital services related to HIV prevention and care.
This collaborative effort, according to Small, is critical in achieving the goal of reducing and eventually eliminating the spread of HIV. Together, these three institutions can avoid the trappings of what Small calls a "cold handoff" by seeing that referrals from one organization to another are personally and individually focused.
All around the U.S., flaws in our system can be traced to origins of abject ignorance or even hostile prejudices.
The result is that a client or patient living with, or at risk of contracting, HIV is not passed from one nameless, faceless entity to another. The referrals provided within the network tend to include personalized consideration of the person being redirected, as well as a unique understanding of various available resources (human and otherwise) that exist within each entity's framework.
This community-focused model of combining education and healthcare works because Vermont has a distinguished presence of nonprofit organizations and dedicated community service workers. Thanks in part to Vermont's relatively low-density population, its low incidence rates of HIV infection and an enhanced emphasis on healthcare that is not driven by revenue or profit, the people working within this avenue of specialized service know each other and know the individuals best suited to serve clients in each office.
It should go without saying that no state is without flaws when it comes to education and access to health services.
"We still see folks who are going to their primary care provider, [the patient] may even bring up PrEP, and the primary care provider says, 'I don't really know much about it so I don't feel comfortable prescribing it,'" Small said.
All around the U.S., flaws in our system can be traced to origins of abject ignorance or even hostile prejudices.
Elsewhere in America
It's no secret HIV care and prevention strategies around the country have to contend with direct political opposition, discriminatory viewpoints on individual and statewide levels, and a significantly denser and more diverse population than in Vermont. These elements create massive obstacles with far-reaching consequences.
MarkAlain Dery, D.O., MPH, FACOI, is a physician in the greater New Orleans area with more than 20 years of experience in HIV care. In regard to the impediments to PrEP education and access in Louisiana, he pointed to some societal issues, which, while still present in other parts of the country, do hold a uniquely significant presence in several Southern states.
"Doctors were slow on the uptake with PrEP because I think that there was a sense of judgment," Dery explained. "There was a judgment that was being placed onto people who were asking about PrEP."
Those biases and negative behaviors within the medical industry contribute to the normalization of initiatives such as abstinence-only sexual education policies, which have been directly tied to increased incidence of HIV transmission. These prevalent attitudes in primary care, as well as other aspects of medicine, are not just an issue in Louisiana and have an impact on PrEP-related advice nationwide.
Without looking at singular circumstances of patient interactions with physicians, it's difficult to say how much of said judgment is rooted in racial-, sexual- or class-based distinctions. However, when you think about the many people who transparently engage in at-risk sexual or drug-oriented behaviors and are unable to obtain information about PrEP from their primary care doctors or other community outlets, it's easy to see these biases still influence the spread of information (or misinformation) and the availability of PrEP access today.
No easy answers
There's no overnight solution to normalizing PrEP discussion in doctor's offices and educational resources around the country, but we can look to organizations and individuals like Small and Dery—and their colleagues in Vermont and Louisiana—to identify a few starting points and successful models of change and intervention.
"How do we support the person holistically?" Small asked, pointing to this question as the driving force behind much of the policy and practice in Vermont. "Which is a radical idea as the rest of our systems are not set up to see the whole person."
Being proactive and advocating for yourself could help circumvent any preconceived notions or stigmas regarding the virus and its treatment.
Radical as it may be, clearly this nonprofit and community-oriented service model from the Green Mountain State is doing something right. Meanwhile, the presence of doctors and other healthcare professionals like Dery (who also helped organize a community radio station that creates accessible PrEP and other HIV-relevant information) is a sign of improvement compared to past obstacles to HIV care and prevention in the South.
If you are someone who engages in behaviors that are classified as more at-risk to contract HIV, ask your doctor about PrEP treatment and for more information regarding the virus. Being proactive and advocating for yourself could help circumvent any preconceived notions or stigmas regarding the virus and its treatment.
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