Factors associated with discussing HIV pre-exposure prophylaxis (PrEP) among Jamaican medical providers

Abstract

Background

The Ministry of Health and Wellness of Jamaica has endorsed the use of pre-exposure prophylaxis (PrEP) as an HIV prevention strategy; however, PrEP was not included in the national HIV prevention program in 2021.

Methods

A cross-sectional online study involving physicians in Jamaica was conducted in 2021 to describe PrEP awareness, beliefs, attitudes, and practices. The study also assessed individual and social factors associated with discussing PrEP with patients and willingness to prescribe PrEP.

Findings

The mean age and standard deviation (SD) of the 69 physicians who completed the survey were 45.5 ± 13.6 years. Most of the participants (80%) reported that they were somewhat familiar with PrEP. PrEP attitude and perceived comfort in prescribing PrEP were moderate among participating physicians, with a mean and SD of 3.9 ± 0.8 and 3.6 ± 0.9 respectively. Six percent of physicians reported that they had prescribed PrEP and 17% had discussed PrEP with their patients in the past year. However, most (90%) reported that they were willing to prescribe PrEP after being informed about it. In the unadjusted model, identifying as Christian (compared to non-Christian) and reporting stronger homophobic beliefs were associated with reduced odds of discussing PrEP with patients. In the multivariable model, only homophobia remained statistically significant (OR, 0.24; 95% CI: 0.07–0.63).

Conclusion

The findings suggest that physicians in Jamacia may be willing to prescribe PrEP; however, homophobia is a barrier to discussions, underscoring the need for the Ministry of Health and Wellness to recognize the role that homophobia plays in the national HIV program to further reduce HIV incidence in Jamaica.

Keywords

Pre-exposure prophylaxis HIV prevention providers Jamaica homophobia stigma

Introduction

Jamaica is currently not on track to achieve the UNAIDS 95-95-95 targets toward ending the HIV epidemic (EHE).¹ The HIV epidemic in Jamaica is characterized as being both generalized and concentrated.¹ The HIV prevalence in the general population is 1.3%; however, among marginalized populations, the prevalence is higher, such as among men who have sex with men (MSM) - 30%, transgender women - 51%, individuals who are incarcerated - 6%, and sex workers - 2%.^1,2 This underscores the need for bolstering Jamaica’s HIV prevention program.^3,4

Pre-exposure prophylaxis (PrEP) is a highly efficacious and scalable biomedical HIV prevention tool that could significantly reduce the burden of HIV and contribute to achieving the UNAIDS EHE goals by 2030.^5–9 Both daily (emtricitabine/tenofovir disoproxil fumarate [FTC/TDF] and emtricitabine/tenofovir alafenamide [FTC/TAF]) and intermittent [FTC/TDF] oral PrEP and the recently approved long-acting injectable PrEP (cabotegravir (CAB-LA)) are highly effective in reducing the risk of acquiring HIV from sexual contact.^10–12 A recent review called for the implementation of policy initiatives to reduce barriers to HIV services and introduce PrEP in Jamaica.¹ However, while the Ministry of Health and Wellness in Jamaica has endorsed the implementation of PrEP for high-risk populations, PrEP was not included in the national HIV prevention program targets.¹

Physicians are gatekeepers to access PrEP; thus, their knowledge, beliefs, attitudes, and practices affect both PrEP messaging and PrEP uptake.^7,13 Discussing PrEP with patients is critical to raising awareness and facilitating decision making for PrEP uptake.¹⁴ Factors such as comfort and skills in conducting HIV risk and PrEP assessments,^15,16 and stigma^7,17 have influenced prescribing among providers.^7,18 Identifying individuals who are potentially eligible for PrEP requires clinicians to ask patients about their sexual behaviors and histories,^19–21 which can be a source of discomfort for providers as well as patients.²²

The purpose of this national, cross-sectional survey among physicians in Jamaica was to: (1) describe PrEP awareness, beliefs, attitudes, and practices; and (2) assess individual, and social factors associated with discussing PrEP with patients and willingness to prescribe PrEP. We framed our inquiry within the socioecological framework^23–25 which underscores the importance of considering multiple levels of influence (e.g., individual, interpersonal, and societal/policy) in conducting research studies and when designing and implementing interventions to change behaviors.²⁵

Methods

Study participants and data collection procedures

We conducted a national cross-sectional, web-based, anonymous survey among physicians in Jamaica using the registries of providers at the Medical Council of Jamaica (MCJ) and the Medical Association of Jamaica (MAJ). The eligibility criteria included being 18 years of age or older and working in any of the following areas of practice in Jamaica: (1) internal medicine, (2) pediatric/adolescent medicine, (3) family medicine, (4) obstetrics and gynecology, (5) infectious diseases, or (6) general practice. Non-physician providers and providers who did not work in one of the areas of practice mentioned above were not eligible to participate. All eligible participants were invited to participate in the study via email from the MCJ or MAJ.

The survey contained previously validated measures and scales (specific measures described below). The survey was pre-tested before it was used to collect the data in Fall 2021 to ensure contextual relevancy. The survey was administered in English. Upon submission of the self-administered survey, which took approximately 30–45 minutes to complete, participants were directed to a separate page where they were given an opportunity to participate in a raffle for a USD $100.00 gift card. Four gift cards were given to participants who were randomly selected from the providers who completed the survey (N = 69). Institutional Review Board (IRB) approval was obtained from Hartwick College, U.S.A, and the Advisory Panel on Ethics & Medical Legal Affairs, Ministry of Health, Jamaica, prior to the start of the study. Online informed consent was obtained from all the participants before they completed the anonymous survey.

Measures

Physician-related factors

Background/socio-demographic factors

Information about age, sex, religion, formal HIV/STI specialty training, and experience of caring for individuals living with HIV was collected.

PrEP knowledge

Participants were asked a single question: “How would you describe your current knowledge about PrEP?” Response options were as follows: (1) Not familiar at all (this is my first-time hearing about it, or I have heard the term but not sure what it is); (2) Somewhat familiar (I am aware of PrEP and the existence of clinical trials but not the details); and (3) Very familiar (I am aware of the details of recent clinical trials).

Attitudes towards PrEP

This was measured using Walsh and Petroll’s, 8-item scale (α=0.80).²⁶ Participants were asked to rate their level of agreement with eight items using a 5-point scale ranging from 1 to 5 with 1 = “completely disagree” to 5 = “strongly agree.” Higher scores are indicative of more positive attitudes towards PrEP.²⁶

Comfort with PrEP-related clinical activities

Walsh and Petroll’s 9-item scale was used to assess this behavioral skill (α = 0.95).²⁶ Participants were asked to indicate their level of comfort while performing key behaviors involved in prescribing PrEP on a 5-point scale ranging from 1 = completely uncomfortable to 5 = completely comfortable. These measures include important precursors to providing PrEP, such as sexual risk assessment, and screening for sexually transmitted infections [STIs] and HIV. Higher scores indicate a greater degree of comfort.²⁶

Homophobia

This was measured using four of the five items on the attitude towards gay men sub-scale on the Attitudes Toward Lesbians and Gay Men Scale (ATLG) short version sub-scale.²⁷ The response options were based on a 5-point Likert scale. Higher scores indicate a greater level of homophobia.

HIV-related stigma and discrimination in health facilities

We adopted three domains: (1) health facility environment, (2) health facility policy, and (3) opinions about people living with HIV from Nyblade et al.’s brief, globally standardized questionnaire for measuring stigma and discrimination in health facilities.²⁸

Health facility environment

First, we asked a screening question: In the past 12 months, have you seen a person living with HIV in your health facility? Response options – yes/no/don’t know. Participants who reported yes were asked: In the past 12 months, how often have you observed the following in your health facility: (1) Healthcare workers unwilling to care for a patient with or thought to be living with HIV; (2) Healthcare workers providing poorer quality of care to a patient living with or thought to be living with HIV, relative to other patients. Responses were based on a 4-point scale: never (0), once or twice (1), several times (2) and most of the times (3).

We calculated a health facility environment score by summing the two items ranging from 0 to 6.²⁸

Health facility policy

This was measured using four questions: (1) I will get in trouble at work if I discriminate against patients living with HIV (yes/no/don’t know); (2) There are adequate supplies at my health facility that reduce my risk of becoming infected with HIV (strongly agree/agree/disagree/strongly disagree); (3) There are standard procedures/protocols that reduce my risk of becoming infected with HIV (strongly agree/agree/disagree/strongly disagree); and (4) My health facility has written guidelines to protect patients living with HIV from discrimination (yes/no/don’t know). We calculated a facility policy score by assigning one point to yes and strongly agree/agree responses, and 0 to no/don’t know and strongly disagree/disagree responses. Higher scores indicate a more favorable policy environment.²⁸

Opinions about people living with HIV (stigmatizing HIV beliefs)

This was measured using four questions: (1) Most people living with HIV do not care if they infect other people; (2) People living with HIV should feel ashamed of themselves; (3) People get infected with HIV because they engage in irresponsible behaviors; and (4) Women living with HIV should be allowed to have babies if they wish. Responses were based on a 4-point scale (1 = strongly disagree to 4 = strongly agree). Items were coded so that higher scores indicated higher levels of stigma, and the mean score was calculated (range 1–4).²⁸

Patient-initiated PrEP discussion

We asked a single question to measure this variable: have any of your patients inquired about PrEP in the past 12 months? (yes/no).

Outcome variables

Discussed PrEP with patients (primary outcome)

This was measured by asking patients: Have you discussed PrEP with any of your patients in the past 12 months? (yes/no).

Willingness/intentions to prescribe PrEP (secondary outcome)

Would you be willing to prescribe PrEP if your health care facility starts offering PrEP? (yes/no). We asked the participants follow-up questions to determine whether the sexual orientation of the client or type of HIV risk behaviors (e.g., substance use, sex work, sexual orientation) would influence their willingness to prescribe PrEP.

Statistical analyses

Descriptive statistics were used to summarize participants’ characteristics. Chi-square or Fisher’s exact test and Student’s t-tests and/or Mann-Whitney-Wilcoxon tests were used to test bivariate statistical associations of the categorical and continuous measures, respectively, by the outcome: ever discussed PrEP with patients in the past 12 months (yes/no). Bivariate analyses were used to identify the factors associated with the outcome. Measures with a two-sided p-value <0.10 in the unadjusted logistic regression models were included in a multivariable logistic regression model; odds ratios and 95% confidence intervals were computed. Measures with reduced response variability and limited sample sizes were excluded from the adjusted model. In addition, we ran a parallel, sensitivity analysis (not presented) among physicians who reported seeing a person living with HIV in the past 12 months (n = 50) and found no statistically significant difference in the results presented. Statistical significance was defined as a two-sided p-value of <0.05. All analyses were performed using R version 4.04 (15 February 2021).

Of the 139 physicians who consented to participate, 69 completed the survey, resulting in a survey completion rate of ∼50%. All analyses were limited to the 69 participants who completed the survey.

Results

The sample demographics are presented in Table 1. The mean age and standard deviation of the 69 physicians who participated in the study were 45.5 ± 13.6 years, 62% were females (this included one trans woman), and 83% self-identified as Christian. Most physicians (74%) had trained in Jamaica and 62% reported that they had no formal specialty training in human immunodeficiency virus and sexual transmitted infections (HIV/STIs). Thirty-eight percent of the physicians were general practitioners, 17% were obstetrics-gynecologists and 45% had other specializations. Only one participant reported specializing in infectious diseases. Approximately half (45%) of the participants practiced in a government facility, 22% practiced at a private hospital or private care center, 22% had their own private practices, and 12% were affiliated with other facilities. Results of the bivariate analyses, comparing socio-demographic covariates between providers who discussed PrEP with their patients in the last 12 months (n = 12, 17.4%) and those who did not (n = 57, 82.6%), found no statistically significant differences except religion (p = 0.04).

Table 1.

Characteristics of physicians (N = 69).

Demographics	Total	Discussed PrEP with patients in the past 12 months
	N = 69 (100.0%)	Yes	No	p-value^a
	N = 69 (100.0%)	n = 12 (17.4%)	n = 57 (82.6%)	p-value^a
Mean age (sd)^b	45.5 (13.6)	47.6 (15.9)	45.0 (13.2)	0.665
Gender				0.799
Male	26 (37.7)	4 (33.3)	22 (38.6)
Female	42 (60.9)	8 (66.7)	34 (59.6)
Trans woman (male to female)	1 (1.4)	0 (0.0)	1 (1.8)
Religious				0.043
Christian	57 (82.6)	7 (58.3)	50 (87.7)
Non-Christian	12 (17.4)	5 (41.7)	7 (12.3)
Medical degree obtained from				0.996
Jamaica	51 (73.9)	9 (75.0)	42 (73.7)
Elsewhere in the Caribbean	12 (17.4)	2 (16.7)	10 (17.5)
Other	6 (8.7)	1 (8.3)	5 (8.8)
Formal HIV/STIs specialty training				0.195
None	43 (62.3)	5 (41.7)	38 (66.7)
Yes, basic/intermediate expert	26 (37.7)	7 (58.3)	19 (33.3)
Specialty of practice				0.393
General practice	26 (37.7)	7 (58.3)	19 (33.3)
Obstetrics-gynecology	12 (17.4)	1 (8.3)	11 (19.3)
Other, specify	31 (44.9)	4 (33.3)	27 (47.4)
Setting of practice				0.674
Government (1 & 2)	31 (44.9)	4 (33.3)	27 (47.4)
Private health care center/hospital	15 (21.7)	4 (33.3)	11 (19.3)
Own private practice	15 (21.7)	3 (25.0)	12 (21.1)
Other	8 (11.7)	1 (8.3)	7 (12.3)
Location of practice				0.279
Northeast regional health authority	5 (7.3)	1 (8.3)	4 (7.0)
Southeast regional health authority	44 (63.8)	10 (83.3)	34 (59.6)
Southern regional health authority	14 (20.3)	0 (0.0)	14 (24.6)
Western regional health authority	6 (8.7)	1 (8.3)	5 (8.8)
Experience treating individuals living with HIV (n = 43)				0.347
None	8/43 (18.6)	2/5 (40.0)	6/38 (15.8)
<2 years	9/43 (20.9)	1/5 (20.0)	8/38 (21.1)
≥2 years	26/43 (60.5)	2/5 (40.0)	24/38 (63.2)

For those measures with missing data sample sizes are included in parentheses and the n’s used for calculating percentages are provided.

^aFisher’s exact test or Mann-Whitney-Wilcoxon test p-value unless otherwise specified.

^bTwo participants missing age.

Most (80%) physicians reported that they were somewhat familiar with PrEP. The scores for PrEP attitude (3.9 ± 0.8) and perceived comfort in prescribing PrEP (3.6 ± 0.9) were moderate (Table 2). Seventeen percent of physicians had discussed PrEP with their patients in the past year and 6% had prescribed PrEP; however, most (90%) reported that they were willing to prescribe PrEP and 10% reported that they were unsure. While the majority (58%) of the providers reported that they would be comfortable prescribing PrEP to all groups, 42% expressed that they would be least comfortable prescribing PrEP to one of the following groups: HIV-negative individuals who inject drugs, sexually active HIV-negative MSM, sexually active HIV-negative transgender individuals, and HIV-negative MSM trading sex in exchange for food or money. Twenty percent reported that their patients had inquired about PrEP within the past 12 months. In the bivariate analyses comparing PrEP-related covariates (e.g., knowledge, attitude, behaviors, and practices) with the outcome (providers who discussed PrEP vs those who did not), there were no significant differences with respect to attitudes and comfort in performing PrEP-related clinical activities. However, physicians who reported being very familiar with PrEP compared to those who were unfamiliar or somewhat familiar were more likely to discuss PrEP with their patients (p = 0.0001). While physicians were more likely to discuss PrEP if patients inquired about PrEP (p ≤ 0.0001), 36% reported not discussing PrEP, although patients had asked about it.

Table 2.

PrEP knowledge and behaviors among physicians.

PrEP knowledge and behaviors	Total	Discussed PrEP with patients in the past 12 months
	N = 69 (100.0%)	Yes	No	p-value^a
	N = 69 (100.0%)	n = 12 (17.4%)	n = 57 (82.6%)	p-value^a
Knowledge about PrEP				0.0001
None	7 (10.1)	0 (0.0)	7 (12.3)
Somewhat familiar	55 (79.7)	6 (50.0)	49 (85.9)
Very familiar	7 (10.1)	6 (50.0)	1 (1.8)
PrEP attitudes mean (sd) (higher score represents greater motivation towards PrEP, scale range: 1–5)	3.9 (0.8)	4.3 (0.8)	3.8 (0.8)	0.095
Comfort in prescribing PrEP mean (sd) (higher score represents greater comfort, scale range: 1–5)	3.6 (0.9)	4.1 (0.94)	3.6 (0.9)	0.071
Patients inquired about (PrEP) in the past 12 months				< 0.0001
Yes	14 (20.3)	9 (75.0)	5 (8.8)
No/missing response	55 (79.7)	3 (25.0)	52 (91.2)
Offered PrEP to patients in the past 12 months				< 0.001
Yes	4 (5.8)	4 (33.3)	0 (0.0%)
No/missing response	65 (94.2)	8 (66.7)	57 (100.0)
Prescribed PrEP to patients in the past 12 months				0.004
Yes	4 (5.8)	3 (25.0)	1 (1.8)
No/missing response	65 (94.2)	9 (75.0)	56 (98.2)
Willingness to prescribe PrEP				0.340
Not sure	7 (10.1)	0 (0.0)	7 (12.3)
Yes (have prescribed/will prescribe PrEP)	62 (89.9)	12 (100.0)	50 (87.7)
Least comfortable prescribing PrEP to (n = 62)				1.000
None	40/62 (58.0)	8/12 (66.7)	32/50 (64.0)
Any^b	22/62 (42.0)	4/12 (33.3)	18/50 (36.0)
Inquire about your patients’ sexual histories				0.484
During each encounter/during annual or routine check-up	30 (43.5)	7 (23.3)	23 (76.7)
Only if the patient has symptoms/signs of STIs (including HIV)	28 (40.6)	4 (14.3)	24 (85.7)
Never/hardly ever conducts sexual history/other	11 (15.9)	1 (9.1)	10 (90.9)

For those measures with missing data sample size is included in parentheses and the n’s used for calculating percentages.

^aFisher’s exact test or Mann-Whitney-Wilcoxon p-value unless otherwise specified.

^bIncludes risk groups based on sexual orientation, substance use and sex work.

Seventy-three percent of the providers reported seeing someone living with HIV at their facility in the past 12 months (Table 3). In the bivariate model comparing stigma-related covariates (health care related stigma, stigma among individuals living with HIV, and homophobia) by the outcome, the groups differed in opinions about MSM (p = 0.0002) and reports of seeing a person living with HIV in the past 12 months (p = 0.028). Physicians who reported higher levels of stigmatizing attitudes towards men who have sex with men were less likely to discuss PrEP. All the physicians who reported discussing PrEP with their patients also reported seeing a patient who lived with HIV in the past 12 months.

Table 3.

Health care related stigma, discrimination and homophobia reported among physicians.

Health care related stigma, discrimination and homophobia	Total	Discussed PrEP with patients in the past 12 months
	N = 69 (100.0%)	Yes	No	p-value^a
	N = 69 (100.0%)	n = 12 (17.4%)	n = 57 (82.6%)	p-value^a
Seen a person living with HIV in the past 12 months				0.028
Yes	50 (72.5)	12 (100.0)	38 (66.7)
No/don’t know	19 (27.5)	0 (0.0%)	19 (33.3)
Health facility environment score mean (sd) (n = 50), scale range: 0–6	0.3 (0.6)	0.3 (0.6)	0.3 (0.6)	0.769
Health facility policies score: mean (sd), scale range: 0–4	2.5 (1.0)	2.8 (1.2)	2.4 (0.9)	0.189
Opinions about people living with HIV score mean (sd) (higher score represents greater stigma, scale range: 1–4)	2.0 (0.6)	1.7 (0.7)	2.1 (0.5)	0.087
Homophobia (opinions about MSM score) mean (sd) (higher score represents greater homophobia, scale range: 1–5)	2.7 (1.1)	1.7 (0.6)	3.0 (1.1)	0.0002

For those measures with missing data sample size is included in parentheses and the n’s used for calculating percentages.

^aFisher’s Exact test or Mann-Whitney-Wilcoxon p-value unless otherwise specified.

When we evaluated the correlates of providers discussing PrEP with patients (yes/no) in a logistic regression model (Table 4), we found that in the unadjusted model, providers who identified as Christian were less likely to discuss PrEP (compared to non-Christians) (odds ratio (OR): 0.20; 95% CI: 0.05–0.81). Similarly, the opinions (stigmatizing beliefs) about people living with HIV score and attitudes about MSM (homophobia) score had an inverse association with providers who discussed PrEP compared to those who did not. With every unit increase in the (negative) opinions about people living with HIV score (stigmatizing beliefs), the odds that the providers discussed PrEP decreased by 69% (OR: 0.31, 95% CI: 0.08–0.98). In addition, with every unit increase in (negative) opinions about MSM score (homophobia), the odds that the providers discussed PrEP decreased by 79% (OR: 0.21; 95% CI: 0.07–0.48). PrEP attitude scores (OR: 2.19; 95% CI: 0.96–5.68) and comfort in prescribing PrEP score (OR: 1.83; 95% CI, 0.91–4.04) were positively associated with increased odds of providers discussing PrEP with patients compared to providers not discussing PrEP with moderate effect estimates; however, these associations were not statistically significant. Further, we were not able to generate stable models for three covariates: (1) PrEP knowledge, (2) patients inquired about PrEP in the past 12 months, and (3) seeing someone living with HIV in the past 12 months in the model due to limited variability in the distribution of each measure’s responses with the outcome.

Table 4.

Factors associated with discussing PrEP in the past 12 months among physicians.

Parameter	Outcome: Discussed PrEP with patients in the past 12 months
Parameter	Unadjusted OR (95% CI)	p-value	Adjusted^a OR (95% CI) (N = 69)	p-value
Christian (vs. non-christians)	0.20 (0.05, 0.81)	.022	0.17 (0.02, 1.20)	0.087
Opinions about people living with HIV score (higher score represents greater stigma)	0.31 (0.08, 0.98)	.060	0.56 (0.10, 2.57)	0.478
Homophobia (opinions about MSM score) (higher score represents greater homophobia)	0.21 (0.07, 0.48)	.002	0.24 (0.07, 0.63)	0.010
Patients inquired about (PrEP) in the past 12 months¹
Yes (vs. no/missing)	27.0 (6.05, 158.4)	<.0001	—	—
Self-report “very familiar” current knowledge about PrEP* (vs.“not familiar at all”/“somewhat familiar”)	56.0 (7.89, 1158.4)	<.001	—	—
PrEP attitude score	2.19 (0.96, 5.68)	.078	1.60 (0.50, 5.98)	0.448
Comfort in prescribing PrEP mean (sd) (higher score represents greater comfort)	1.83 (0.91, 4.04)	.106	1.29 (0.55, 3.24)	0.566

^aDue to limited variability in the distribution of the measure’s responses with the outcome, the following variables were excluded from the adjusted model: (1) seen a person living with HIV in the past 12 months; (2) patients inquired about PrEP in the past 12 months; and (3) PrEP knowledge.

In the fully adjusted model (Table 4) that included religion, stigmatizing attitudes towards MSM score (homophobia), stigmatizing beliefs about people living with HIV score, PrEP attitude score and comfort in prescribing PrEP score, only homophobia (stigmatizing attitude towards MSM score) remained statistically significant (OR: 0.24; 95% CI: 0.07–0.63).

Discussion

To our knowledge, this cross-sectional study is the first to assess knowledge, attitudes, and willingness to prescribe PrEP among physicians in Jamaica as well as evaluate factors associated with discussing PrEP with patients. The findings suggest that providers who had stronger homophobic beliefs were less likely to report discussing PrEP with their patients in the past 12 months. The results from the main and sensitivity analyses (restricted model with only providers who reported seeing someone living with HIV in the past 12 months) were similar (increased homophobia was associated with reduced odds of discussing PrEP). Studies have shown that some MSM are hesitant to disclose their sexual orientation to their primary providers^18,29 because of the stigma associated with same-sex sexual behavior among men. MSM in Jamaica often experience social stigmatization, homophobia,^1,30 and violations of human rights related to same-sex behavior.^31–33 This may in part be attributable to factors such as gender norms (expected standard of behaviors for males and females in a given society),^33,34 and criminalization of same-sex sexual behavior among men.³³

MSM often experience stigma and discrimination at multiple levels within the society (e.g., family, institutions, and community).³³ These experiences may discourage longer-term relationships, and encourage anonymous and condomless sex, as well as avoidance of health services.^1,4,30 Over 50% of MSM in Jamaica report having sex with females.^1,30 HIV stigma and homophobia intersect in Jamaica, which may be driving the HIV epidemic among MSM and undermining uptake of HIV prevention and support services.³² Studies elsewhere have shown that provider stigma and discrimination including heterosexism can undermine access to PrEP.^35,36 Given the epidemiological profile and dynamics of HIV among MSM in Jamaica, the need for urgent measures to increase PrEP uptake including reducing homophobia among providers is necessary to halt the HIV epidemic.

Although most providers were not very familiar with PrEP, did not discuss PrEP with their patients or prescribe PrEP within the past 12 months, they were willing to prescribe PrEP after they were given information about it. In addition, attitudes towards PrEP and comfort with performing PrEP-related tasks are encouraging and suggest that providers would be willing to support a PrEP program in Jamaica. Of note, only one physician reported working in infectious diseases and over 50% worked in general practice or gynecology and obstetrics. Furthermore, a sizable proportion (45%) worked at a government-led facility. Calabrese and colleagues³⁷ suggest routinizing PrEP in primary health care settings is essential for ensuring improved and equitable access to PrEP. The authors highlighted four principal benefits for routinizing PrEP which could halt the spread of HIV and reduce HIV disparities: (1) significantly reduces the risk of missing potential individuals who are eligible for PrEP; (2) reduces stigma associated with uptake of PrEP among eligible candidates; (3) facilitates patient-centered care; (4) promotes awareness of PrEP among MSM and the general community.³⁷ Overall, the findings from our study (e.g., limited experience prescribing and discussing PrEP, higher levels of homophobia associated with reduced odds of discussing PrEP, and lack of formal training in STIs, with 62% reported no formal training in STIs) suggest a robust training program is required to build providers’ capacity to prescribe PrEP.

This study has several limitations that should be considered when interpreting the findings. First, the small convenience sample was not representative of providers in Jamaica. The low response rate also limits the generalizability of our findings. In addition, the analyses were limited to the participants who completed the survey. The low survey completion rate is likely attributable to the length of the survey and demanding schedule of providers. Second, the small sample size, coupled with the lack of variability in responses to some key questions, limited the rigor of the statistical analyses that were performed and precision of the estimates that were generated. The lack of statistically significant associations observed with a number of covariates assessed in the logistic regression model may be due to the small sample size. We were also not able to determine the relationship between three covariates (PrEP knowledge, patient-initiated PrEP discussion and seeing someone living with HIV) due to unstable models. In addition, we were unable to determine the factors associated with willingness to prescribe PrEP because none of the participants reported that they were unwilling to prescribe PrEP. Third, the self-reported data collected are subject to information bias. Fourth, the cross-sectional study design prevents us from making causal inferences.

Despite these limitations, our findings provide valuable insights about providers’ knowledge, attitudes, and willingness to prescribe PrEP which could inform the Ministry of Health and Wellness plans to include PrEP in the national HIV prevention program. Moreover, the findings provide preliminary data to inform future PrEP studies among providers in Jamaica and highlight the urgent need for conducting studies on provider-level interventions to increase PrEP knowledge and prescribing among providers in Jamaica.

Footnotes

Authors contributions

MMW along with her team of mentors (JPF, HVT, AD, EW) developed the research study and prepared the manuscript. MW contributed to the development of the project and suggested implementation strategies. VN conducted the statistical analysis and AD, MT, MMW and VF assisted with the interpretation and presentation of the data. All authors contributed to reviewing and editing of the manuscript.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Hartwick College, and the HIV Intervention Science Training Program for Underrepresented New Investigators (Grant # R25MH080665) at the Columbia School of Social Work.

ORCID iD

Melonie M Walcott

Data availability statement

Research supporting this publication area available upon request.

References

Figueroa

Duncan

Bailey

, et al. The HIV epidemic in Jamaica: a need to strengthen the national HIV program. Rev Panam Salud Públic 2020; 44: e157. DOI: 10.26633/RPSP.2020.157

UNAIDS . Focus on Jamaica, https://www.unaids.org/en/20191107_country_focus_Jamaica (2022, accessed 11 Novemeber, 2022.

Cushnie

Reintjes

Lehtinen-Jacks

, et al. HIV program outcomes for Jamaica before and after “treat all”: a population-based study using the national treatment services database. PLoS One 2021; 16: e0255781. DOI: 10.1371/journal.pone.0255781

Logie

Lacombe-Duncan

Brien

, et al. Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston, Jamaica: a qualitative study. J Int AIDS Soc 2017; 20: 21385. DOI: 10.7448/IAS.20.1.21385

Sullivan

Mouhanna

Mera

, et al. Methods for county-level estimation of pre-exposure prophylaxis coverage and application to the U.S. Ending the HIV Epidemic jurisdictions. Ann Epidemiol 2020; 44: 16–30. DOI: 10.1016/j.annepidem.2020.01.004

Ssempijja

Nakigozi

Ssekubugu

, et al. High rates of pre-exposure prophylaxis eligibility and associated HIV incidence in a population with a generalized HIV epidemic in Rakai, Uganda. J Acquir Immune Defic Syndr 2022; 90: 291–299. DOI: 10.1097/QAI.0000000000002946

Pleuhs

Quinn

Walsh

, et al. Health care provider barriers to HIV pre-exposure prophylaxis in the United States: a systematic review. AIDS Patient Care STDS 2020; 34: 111–123. DOI: 10.1089/apc.2019.0189

Eisinger

Fauci

. Ending the HIV/AIDS pandemic (1). Emerg Infect Dis 2018; 24: 413–416. DOI: 10.3201/eid2403.171797

Stover

Bollinger

Izazola

, et al. What is required to end the AIDS epidemic as a public health threat by 2030? The cost and impact of the fast-track approach. PLoS One 2016; 11: e0154893. DOI: 10.1371/journal.pone.0154893

10.

Nunn

Brinkley-Rubinstein

Oldenburg

, et al. Defining the HIV pre-exposure prophylaxis care continuum. AIDS 2017; 31: 731–734. DOI: 10.1097/QAD.0000000000001385

11.

Durham

Milam

Waer

, et al. Cabotegravir: the first long-acting injectable for HIV preexposure prophylaxis. Ann Pharmacother 2022; 57: 306–316. DOI: 10.1177/10600280221102532

12.

Landovitz

Donnell

Clement

, et al. Cabotegravir for HIV prevention in cisgender men and transgender women. N Engl J Med 2021; 385: 595–608. DOI: 10.1056/NEJMoa2101016

13.

Lelutiu-Weinberger

Golub

. Enhancing PrEP access for black and Latino men who have sex with men. J Acquir Immune Defic Syndr 2016; 73: 547–555. DOI: 10.1097/QAI.0000000000001140

14.

Carneiro

Frye

Mirzayi

, et al. What predicts a clinical discussion about PrEP? Results from analysis of a U.S. national cohort of HIV-vulnerable sexual and gender minorities. AIDS Educ Prev 2022; 34: 195–208.

15.

Krakower

Mayer

. Engaging healthcare providers to implement HIV pre-exposure prophylaxis. Curr Opin HIV AIDS 2012; 7: 593–599. Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov’t Review 04/10/2012. DOI: 10.1097/COH.0b013e3283590446

16.

Carter

Aaron

Nassau

, et al. Knowledge, attitudes, and PrEP prescribing practices of health care providers in Philadelphia, PA. J Prim Care Community Health 2019; 10: 2150132719878526. DOI: 10.1177/2150132719878526

17.

Calabrese

Tekeste

Mayer

, et al. Considering stigma in the provision of HIV pre-exposure prophylaxis: reflections from current prescribers. AIDS Patient Care STDS 2019; 33: 79–88. DOI: 10.1089/apc.2018.0166

18.

Adeagbo

Harrison

Qiao

, et al. Pre-exposure prophylaxis (PrEP) uptake among black men who have sex with men (BMSM) in the southern U.S. Int J Environ Res Public Health 2021; 18. DOI: 10.3390/ijerph18189715

19.

Golub

Gamarel

Lelutiu-Weinberger

. The importance of sexual history taking for prep comprehension among young people of color. AIDS Behav 2017; 21: 1315–1324. DOI: 10.1007/s10461-016-1512-9

20.

Moore

Kelly

Alexander

, et al. Tennessee healthcare provider practices, attitudes, and knowledge around hiv pre-exposure prophylaxis. J Prim Care Community Health 2020; 11: 2150132720984416. DOI: 10.1177/2150132720984416

21.

Lanier

Castellanos

Barrow

, et al. Brief sexual histories and routine HIV/STD testing by medical providers. AIDS Patient Care STDS 2014; 28: 113–120. DOI: 10.1089/apc.2013.0328

22.

Lumsden

Dave

Johnson

, et al. Improving access to pre-exposure prophylaxis for HIV prescribing in a primary care setting. BMJ Open Qual 2022; 11. DOI: 10.1136/bmjoq-2021-001749

23.

Wang

Mitchell

Zhang

, et al. Evidence and implication of interventions across various socioecological levels to address pre-exposure prophylaxis uptake and adherence among men who have sex with men in the United States: a systematic review. AIDS Res Ther 2022; 19: 28. DOI: 10.1186/s12981-022-00456-1

24.

Pinto

Lacombe-Duncan

Kay

, et al. Expanding knowledge about implementation of pre-exposure prophylaxis (PrEP): a methodological review. AIDS Behav 2019; 23: 2761–2778. DOI: 10.1007/s10461-019-02577-7

25.

Golden

Wendel

. Public health’s next step in advancing equity: re-evaluating epistemological assumptions to move social determinants from theory to practice. Front Public Health 2020; 8: 131. DOI: 10.3389/fpubh.2020.00131

26.

Walsh

Petroll

. Factors related to pre-exposure prophylaxis prescription by U.S. primary care physicians. Am J Prev Med 2017; 52: e165–e172. DOI: 10.1016/j.amepre.2017.01.025

27.

Siebert

DCCJ

Siebert

Rutledge

. The importance of confirmatory validation: short version of the attitudes toward lesbians and gay men scale. J Soc Soc Work Res 2014; 5: 2334–2351.

28.

Nyblade

Jain

Benkirane

, et al. A brief, standardized tool for measuring HIV-related stigma among health facility staff: results of field testing in China, Dominica, Egypt, Kenya, Puerto Rico and St. Christopher & Nevis. J Int AIDS Soc 2013; 16: 18718. DOI: 10.7448/IAS.16.3.18718

29.

Metcalfe

Laird

Nandwani

. Don’t ask, sometimes tell. A survey of men who have sex with men sexual orientation disclosure in general practice. Int J Std AIDS 2015; 26: 1028–1034. DOI: 10.1177/0956462414565404

30.

Dunbar

Pape

Coppieters

. HIV among men who have sex with men in the Caribbean: reaching the left behind. Rev Panam Salud Públic 2021; 45: e12. DOI: 10.26633/RPSP.2021.12

31.

Logie

Wang

Marcus

, et al. Pathways from sexual stigma to inconsistent condom use and condom breakage and slippage among MSM in Jamaica. J Acquir Immune Defic Syndr 2018; 78: 513–521. DOI: 10.1097/QAI.0000000000001712

32.

Andrinopoulos

Figueroa

Kerrigan

, et al. Homophobia, stigma and HIV in Jamaican prisons. Cult Health Sex 2011; 13: 187–200. DOI: 10.1080/13691058.2010.521575

33.

Smith

. Homophobic and transphobic violence against youth: the Jamaican context. Int J Adolesc Youth 2018; 23: 250–258. DOI: 10.1080/02673843.2017.1336106

34.

Walcott

Funkhouser

Aung

, et al. Gender norms and sexual behaviours among men in western Jamaica. Sex Health 2014; 11: 42–51. DOI: 10.1071/SH13099

35.

Calabrese

Earnshaw

Krakower

, et al. A closer look at racism and heterosexism in medical students’ clinical decision-making related to HIV pre-exposure prophylaxis (PrEP): implications for PrEP education. AIDS Behav 2018; 22: 1122–1138. DOI: 10.1007/s10461-017-1979-z

36.

Storholm

Ober

Mizel

, et al. Primary care providers’ knowledge, attitudes, and beliefs about HIV pre-exposure prophylaxis (PrEP): informing network-based interventions. AIDS Educ Prev 2021; 33: 325–344. DOI: 10.1521/aeap.2021.33.4.325

37.

Calabrese

Krakower

Mayer

. Integrating HIV preexposure prophylaxis (PrEP) into routine preventive health care to avoid exacerbating disparities. Am J Public Health 2017; 107: 1883–1889. DOI: 10.2105/AJPH.2017.304061