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Implicit Bias to PrEP
Our Biases Are Showing: Addressing Barriers to Providing PrEP to Adolescents

Released: November 28, 2023

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Key Takeaways
  • Implicit bias can affect whether healthcare professionals view an adolescent as a candidate for PrEP and can reduce opportunities for PrEP education and access to PrEP.

There are nuances to providing pre-exposure prophylaxis (PrEP) for HIV prevention to adolescents, including consent laws, lack of access to sexual health education, confidentiality for PrEP and sexually transmitted infection screening services, and social determinants of health (eg, transportation, location of adolescent-friendly services, costs).

However, even as communities strive to address these barriers, one barrier may remain deep-rooted in our very core. This barrier is our own sexual health‒ and HIV-associated bias. I believe this bias is most visible in the way we discuss PrEP.

Assumptions Lead to Implicit Bias
In 2021, the CDC updated their PrEP guidelines to state that PrEP should be discussed with all sexually active adolescents and adults. The inclusion of the word “adolescents” was intentional, as adolescents account for 10% to 15% of PrEP use while simultaneously accounting for 20% to 25% of new HIV infections in the United States.

Oftentimes, we as healthcare professionals view adolescents who present for our services as if they were our own children, grandchildren, or relatives. We disregard how those perceptions may contradict the training and real-life experiences we have with adolescent development. We think to ourselves: “That’s a great child. That’s a great student or a great athlete. They’re not having sex, or if they are having sex, they’re having safe sex.”

In reality, many adolescents have not had comprehensive sex education and may be practicing suboptimal sexual health behaviors. For example, we do not know if they are having open, honest conversations with their partners about sex. We do not know if they are getting tested for sexually transmitted infections regularly or if their partner(s) have been tested. Are they engaging with age-appropriate and developmentally appropriate partners? Are they making sober decisions to engage in sex?

We make assumptions because we identify that person as our own child, son, daughter, niece, nephew, or grandchild. Although these character assumptions may seem positive, they are a sign of our subconscious bias. We feel familiarity with these teens, so we may not consider offering them PrEP. Whether we realize it or not, most of us have this implicit bias, and it results in fewer opportunities to provide education and access to PrEP.

PrEP Is for Everyone
Some may say that adolescents we feel familiarity with are less likely to acquire HIV, but I would argue that as an HIV provider to youth and young adults, I have met plenty of adolescents of varying genders, races, socioeconomics, and sexual preferences who acquired HIV from their teenage significant other or after having only 1 or 2 lifetime partners.

We have a highly effective biomedical tool that has been trialed and approved for use in adolescents. It has CDC recommendations and a grade A recommendation from the US Preventive Services Task Force. We should not let our bias prevent us from using this tool. All healthcare professionals who interact with adolescents have the opportunity to decrease HIV incidence in young adults. We must continually challenge our biases and facilitate discourse about PrEP among adolescents and those who support them in their health.

We did it with adolescent girls and contraception, and we can do it with PrEP!

Your Thoughts?
Have you realized that implicit bias affects how you discuss PrEP with your patients? How do you challenge your own implicit biases? Leave a comment to join the discussion.