Medical Students' Perspectives on HIV Prevention Education in the Preclinical Years

Abstract

Editor: In previous evaluations of pre-exposure prophylaxis (PrEP) awareness among primary care providers in Miami, only 6% reported prescribing PrEP.¹ Effective implementation of prevention strategies requires provider education.² As Miami-Dade County has the highest rate of new HIV infections in the United States, training of medical students in Miami in HIV prevention strategies is of particular importance.³ In this study, we assessed perceived adequacy of the HIV prevention curricula and attitudes toward PrEP among medical students at the University of Miami. Results from this study may help inform future curricular development.

A total of 112 first and second year medical students in either traditional (MD) or dual degree (MD/MPH) programs were included in our study (Table 1). Overall, 48% of students indicated having “some knowledge” of PrEP before the survey and 72% of students indicated willingness to recommend PrEP. Students reported receiving information about HIV prevention through lectures (76.8%), problem-based learning and small groups (63.4%), outside of formal medical education (66.1%), and social media (48.2%). Formal instruction regarding PrEP was reported by 14.3%. Students more commonly reported learning about behavioral counseling (57.1%) and HIV treatment (67%). The majority of students (63.4%) described their education regarding HIV prevention as “somewhat adequate.” Of 65 respondents, 55.3% of students indicated that the lecture format was preferred for the provision of additional HIV prevention education. Among respondents, 82.2% believed that PrEP should be offered to at-risk patients and 66.1% suggested that government programs should fund PrEP for those at increased risk for HIV infection unable to afford medication. Adherence, cost, and lack of knowledge were identified as barriers to the use of the medication. There was no statistically significant relationship between program track (MD or MD/MPH) and responses.

Table 1.

Demographics and Responses by Cohort of Medical Students Completing Pre-Exposure Prophylaxis Knowledge Surveys

Characteristics	Total	MD	MD/MPH
No. of participants^a	112	43	69
Gender identity (n = 111)
Female	54	13	41
Male	57	29	28
Race (n = 111)
Asian	26	11	15
Black	6	1	5
Multirace	7	3	4
Other	3	1	2
White	69	27	42
Hispanic/Latino
Yes	11	8	3
No	100	35	65
Average age	24.3	27.5	24.5

PreP knowledge questions	% Correct	MD	MD/MPH
Select the city with the highest incidence of new HIV infections in 2013	89.3	79.1	95.7
In Miami, which of the following groups has the highest rate of new HIV infections (by type of risk)	39.3	39.5	39.1
In Miami, which of the following groups has the highest rate of new HIV infections (by race)	73.2	72.1	73.9
Through which of the following ways can HIV be transmitted:
Sharing needles	96.4	100	94.2
Casual contact (hugging, shaking hands)	100	100	100
Anal/vaginal sex	98.2	97.7	98.6
Mosquitoes, ticks, or other insects	98.2	97.7	98.6
From mother to child during pregnancy, childbirth, breastfeeding	92.9	93	92.8
Which of the following are evidence-based methods for preventing HIV infections:
Abstinence	79.5	88.4	73.9
Consistent and correct condom use	96.4	100	94.2
PrEP	83	76.7	87
PEP	70.5	62.8	75.4
Treatment for HIV-positive persons	58	62.8	55.1
Please select the dosing schedule for emtricitabine/tenofovir (Truvada^®) PrEP (n = 108)	67	52.5	75
PrEP medication can only be obtained from research studies	80.4	69.8	87
How often is it recommended that patients using PrEP be tested for HIV	50.9	34.9	60.9
Once a patient starts using PrEP, he/she must continue taking the medication for life (n = 111)	82	79.1	83.8
PrEP protects against sexually transmitted infections such as chlamydia and gonorrhea (n = 110)	93.6	85.7	98.5
The FDA has approved a medication for PrEP (n = 111)	85.5	73.8	92.6
Who should receive PrEP:
Men who have sex with men	78.6	79.1	78.3
Women who have sex with women	69.6	58.1	76.8
Transgender females at high risk for HIV infection	80.4	72.1	85.5
Transgender men at high risk for HIV infection	83	76.7	87
Heterosexual women at high risk for HIV infection	80.4	74.4	84.1
Heterosexual men at high risk for HIV infection	80.4	74.4	84.1
Discordant couples	43.8	34.9	49.3
Discordant couples planning pregnancy	42.9	32.6	49.3
Injection drug users at high risk for HIV infection	87.5	88.4	87

Total responses per survey question are n = 112, unless otherwise specified.

FDA, Food and Drug Administration; PEP, postexposure prophylaxis; PrEP, pre-exposure prophylaxis.

Availability of providers is a limitation in PrEP implementation in the United States.⁴ Expanding medical students' education in PrEP could impact future willingness to recommend PrEP for populations at risk for HIV. In our survey of medical students, the majority indicated willingness to prescribe PrEP in their future practices, but reported variable formal training and gaps in knowledge of PrEP availability and logistics. Prevalent cost concerns highlight the need for inclusion of information regarding cost assistance programs and cost-effectiveness in HIV prevention education.

Increased exposure to information regarding HIV prevention and PrEP has been shown to increase willingness to prescribe PrEP.⁴ As physician specialists may receive variable training in HIV prevention after medical school, the preclinical curriculum provides a common ground for future physicians and is a reasonable target for dissemination of information. Although many students in our survey expressed a preference for lecture format, small group settings may be appropriate to consider for the necessarily nuanced discussion of these prevention strategies.

Our survey assesses basic PrEP knowledge, but does not address stigma regarding HIV transmission nor salient nuances in HIV prevention implementation. Further research is necessary to develop a more extensive assessment of medical students' knowledge of HIV prevention strategies and address knowledge gaps through standardized preclinical medical curricula.

References

Petroll

, Walsh

, Owczarzak

, McAuliffe

, Bogart

, Kelly

: PrEP awareness, familiarity, comfort, and prescribing experience among US primary care providers and HIV specialists. AIDS Behav, 2017; 21:1256–1267.

Smith

, Mendoza

, Stryker

, Rose

: PrEP awareness and attitudes in a National Survey of Primary Care Clinicians in the United States, 2009–2015. PLoS One, 2016; 11:e0156592.

Centers for Disease Control and Prevention: HIV Surveillance Report; Vol. 28. Available at www.cdc.gov/hiv/library/reports/hiv-surveillance.html (2017), accessed February 27, 2018 .

Krakower

, Mayer

: The role of healthcare providers in the roll-out of PrEP. Curr Opin HIV AIDS, 2016; 11:41–48.