Sarah Calabrese: PrEP and HIV Prevention

Sarah Calabrese is an Assistant Professor of clinical psychology at The George Washington University. Her research focuses on sexual health promotion among racial and sexual minorities and other socially marginalized groups. Sarah chats with Valerie about all things PrEP (an HIV prevention medication), including: how many people are (or aren’t) using PrEP, (arguably) conservative guidelines around PrEP recommendations, and provider bias in PrEP prescription that likely leads to inequities in who can access PrEP. Valerie asks Sarah about why it’s important to think about sexual pleasure when we’re studying HIV prevention and sexual health promotion. 

Learn more about Sarah’s work here: https://shel.columbian.gwu.edu/

Transcript

Valerie Earnshaw: 0:11

I'm Valerie Earnshaw.

Carly Hill: 0:13

I'm Carly Hill.

Valerie Earnshaw: 0:14

and this is Sex Drugs and Science.

Carly Hill: 0:17

Today's conversation is with Sarah Calabrese, who is an assistant Professor of Psychology at George Washington University. Her research focuses on sexual health promotion among racial and sexual minorities and other socially marginalized groups.

Valerie Earnshaw: 0:32

A key part of Sarah's work aims to identify and address barriers to HIV prevention, including pre-exposure prophylaxis or PrEP. So PrEP is a daily pill that can be taken to prevent HIV. It's actually a really important medication. It's super promising in reducing the spread of HIV. But interestingly enough, not a lot of people are taking it. So we try to understand why more people aren't taking PrEP when we taught it with Sarah.

Carly Hill: 1:00

And you guys will notice for this episode that I am missing. I got into a little fender bender on the way to record the podcast, but I, you know, knew that Valerie could somehow handle the show without me. So I think you'll find she did a great job.

Valerie Earnshaw: 1:16

Well, my parts are only, you know, it's like 30% is good without, without, but again, if folks have complaints about the episode, they can send those complaints to Kim Nelson. Yes. KayNels@[inaudible]com. So please do send any complaints that way, but anyway, Carly, we super miss you, super glad that everything's okay. And we hope that everyone out there enjoys this conversation with Sarah Calabrese. All right. Dr. Calabrese is thanks for joining us on the podcast.

Dr. Sarah Calabrese: 1:51

I'm happy to be here. Thanks for having me.

Valerie Earnshaw: 1:53

So, Sarah, you received your PhD in clinical psych from George Washington university. And I realized that although we've known each other for almost a decade now, and also, I feel like I could order for you at sushi. We,'ve had our sushi dates, that I actually don't know, like the backstory in terms of why you decided to pursue clinical psych specifically.

Dr. Sarah Calabrese: 2:22

Yeah. So in college I was a double major in biology and psychology and the original plan was to go into medicine. I became very interested in psychological science and kind of how psychological processes related to health. And so for that reason, clinical psych seems like a good fit. And the idea of a clinical psych PhD was desirable because I would get training in both research as well as clinical work, if I wanted to go down that path, which I wasn't sure about at the time. So also I think that medicine would have been a terrible thing for me in retrospect, because I'm super squeamish. And so I think this is really the best way to go.

Valerie Earnshaw: 3:03

That's awesome. That's really interesting that you were interested in medicine. I didn't know that. And that makes sense. I mean, we'll talk about this more, but you've developed this big interest in this like biomedical technology, this like, PrEP, which is an HIV prevention pill, so, or HIV prevention medication, even though you didn't pursue the MD, you're still like very much working in that area. So,

Dr. Sarah Calabrese: 3:28

And also studying MDs. Right? A lot of my work is around healthcare providers and provider bias. So yeah, I guess I didn't totally get away from medicine.

Valerie Earnshaw: 3:41

So when you were in your grad program, it sounds like your particular grad program was like a really terrific fit for you because you were in the clinical psych program at George Washington. And there are a bunch of folks who have this interest in science and medicine. And I saw that you worked on a study of HIV medication adherence and disclosure while you were a grad student. So is that where your like, interest in HIV started to percolate?

Dr. Sarah Calabrese: 4:07

So I think my interest in HIV really started back in college, like going into grad school, you know, you apply to work with a particular mentor. And so I applied to work with Dr. Maria Cecilia Zea because of the work that she was doing around understanding HIV risk and prevention with Latino MSM. So the interest in HIV started prior to that, and it was just, it's always been something that I've gravitated towards. I think a lot of people have these personal stories or like a personal connection, like they, or a loved one diagnosed. And like that wasn't the case, but I always just felt connected to HIV. And I think that probably part of that is recognition that it disproportionately affects communities that are already disadvantaged, recognizing that that was a social problem. And then I think also there was intellectual curiosity because on the one hand we had prevention tools that we knew worked. And so in theory, HIV could be prevented and yet, clearly it wasn't being prevented. The spread was still happening. And so I wanted to understand what the barriers were to the use of existing tools. So I think that's kind of where my interest in HIV came from. And then when I went to grad school, I went specifically to work with Maria Cecilia and then, yeah, I mean, as he spoke to, it was a good fit in terms of the work people were doing there. And other people were interested in work that was really more community focused and applied health. And so all of those things appeal to me.

Valerie Earnshaw: 5:42

It's really interesting hearing you talk about it because I think I was like attracted to studying HIV in grad school for similar reasons. You know, I think I developed my interest in stigma earlier, but then HIV is just such like a perfect playing field to study stigma, all of these social dynamics or health disparities. I mean, HIV is terrible. That it's the case, but because there are so many disparities because of some of these issues that you're highlighting around, you know, we know what stops HIV transmission, why is it happening? You know, it's really interesting place to work, I think, as the scientists, but maybe even, especially like as a social scientist.

Dr. Sarah Calabrese: 6:22

Yeah, yeah. Like really understanding some of those social factors and social processes that are contributing to the spread.

Valerie Earnshaw: 6:29

Yeah. Yeah. All right. Well then both of our paths converge, when we were post- docs. So we both did the post-doctoral fellowship at the center for interdisciplinary research on aids at Yale university. And as I was thinking through your timeline, I was like, oh wow, because you were a post-doc at this really fantastic place to, you know, study HIV and dig in to HIV research. Although you had started that earlier, but at the same time that PrEP is approved by the FDA. So is that then where the interest in PrEP starts to emerge or where had you been interested in it beforehand? Because the trials for it had been going on for some years before FDA gave the green light for folks to use it.

Dr. Sarah Calabrese: 7:17

Yeah. I mean, I think that my interest really took off sort of, end of grad school, beginning of post doc. You know, it really coincided with the release of the results from iPrEx and the, which is a clinical efficacy study, as well as other clinical studies and then FDA approval in 2012. That was all around the time that I was doing my postdoc. And I think in grad school PrEP was on the radar and particular microbicides, but it was really at the time I wasn't doing work related to that. It was really kind of once the trial results were released that looked so promising once FDA approval occurred and PrEP just seemed fantastic. PrEP is fantastic, but you know, it really just seemed like this game changer or like all of a sudden we've been struggling to curb the spread of HIV because of X, Y, and Z reasons. And like, we keep trying to push these other prevention methods, but clearly it's not enough. And then like suddenly PrEP comes on the scene and it circumvents so many of the challenges associated with other prevention options. And so how could you not get excited about that? I think that, you know, my research is just kind of moving with the science and it was in grad school, as you know, that I did that, we did that initial study where we looked at medical students and their clinical judgment and clinical decision-making related to PrEP and how it may differ according to the race of the patient and getting those initial results that suggested that biases could come into play when it came prescribing PrEP. And that could have implications for access. I think that really just laid the foundation for my subsequent research trajectory.

Valerie Earnshaw: 9:06

Arc is lit. I remember going to a conference with you in New York city. I don't remember much about the conference, but I do remember sitting at these like long tables with you. And you were thinking about that study and you were talking it through out loud and sometimes, you know, you talk to people about their research ideas and you're like, I don't know if you are really into this part, you know, but you were like, you were all lit up about it. You like follow that this, that you were like really excited about it. And oftentimes, you know, you, you leave the conference, you leave the room and you don't do the study, but you did the study, and then some, which is like really amazing. So I'll have to come back to the methods of that.

Dr. Sarah Calabrese: 9:47

I was thinking about that conference as well. I think that's really where the idea initially you took off. And I remember you being there really encouraging me. And I think that you were instrumental in me actually carrying out the study because you were so encouraging and excited about it as well. So thank you for that.

Valerie Earnshaw: 10:05

Oh, hey. It's like really easy to be excited and encouraging of like a really excellent idea. So I'll just wrap up the career trajectory part and then I'll push us to talk more about like what PrEP actually is, because I'm sure some folks are wondering. But I just want to mention that after postdoc and a few additional years at Yale, that you returned to GW, George Washington University as a faculty member in 2016. And I just want to put out there that that's quite remarkable because many graduate students, when they're doing their training, there, they're very much warned that it is difficult to be hired by the department that trained you. You'll never say this, but it's quite a big deal. And it really speaks to the quality of your work, I think, that your department wanted you back grad student, like they saw the worst of me. So the fact that they were like,"oh, bring Sarah back" is quite an accomplishment. And I think, yeah, it just really speaks to what great work you're doing so.

Dr. Sarah Calabrese: 11:07

Well that's very kind of you to say. And I mean, I think that that was knowing the department and knowing the program is why it was such a big draw for me as well. Like just having that familiarity, knowing who my colleagues would be, knowing the kind of work people were doing, the environment, the setting, DC, all of it. It's just, I enjoyed it in grad school. And I was really excited to have the opportunity to come back.

Valerie Earnshaw: 11:32

Yeah. It's a really phenomenal department for people, especially like you who have this interest in inequity, social factors, crossovers with like medicine and, and health. It's like, it's a, it's a pretty unique psychology department in that way.

Dr. Sarah Calabrese: 11:49

It really is. I don't know how many psychology departments my stuff would really fit in. And GW just struck me as so unique because as I said, there really is an intersection of psychology and public health. And particularly is related, a lot of people do work related to HIV in our department, but also at GW there is a NIH funded center that's based in GW and encompasses many institutions in DC. So like, it's really a ideal place to be doing HIV research.

Valerie Earnshaw: 12:20

Yeah. Okay. So now we've been talking about it for like 15 minutes. So maybe we could talk about what PrEP is for folks who may not be familiar with it. Maybe think about who is eligible for PrEP. Cause not everyone is prescribed PrEP, although maybe they should be, but

Dr. Sarah Calabrese: 12:38

Yes. So PrEP is Pre-exposure Prophylaxis and it is medication that is taken on an ongoing basis by somebody who is HIV negative in order to prevent the acquisition of HIV. It's incredibly effective, at least 99%, which, I mean, that's just unreal. That's- people hesitate or you know object, to calling it a silver bullet, but I don't understand why we don't, it feels like it is! Currently the form of PrEP that is FDA approved is a once a day pill. There's a couple of different formulations, but there are other dosing and delivery strategies that are kind of in the pipeline, event-driven dosing, where you're not taking medication every day, but you're taking it around the time of a potential transmission event. There's also different delivery strategies that are in a lot of ways sort of like birth control. So there's injections, there's implants, there's rings, et cetera. So, you know, these are various stages of testing and development, but I think that it's very promising in terms of what might be available down the line. But for right now, in the US, it's a once a day pill.

Valerie Earnshaw: 13:50

Yeah. It's exciting to hear about all the, like all the various ways that it could come out, down the, down the line, especially like as women or as I'll just do to myself, like as a woman, having so many options for birth control is really helpful, you know, and different things work best for different people. So the idea that there's going to be more options for folks, that's really exciting.

Dr. Sarah Calabrese: 14:11

Yeah. I love that aspect of it. And you also asked about eligibility. So this is maybe a controversial issue. I mean, it's something that is approved for US adults who are at risk because of their sexual behavior or because of their injection drug practices, for example, sharing needles. Those are the people who could benefit from it. And it's also available, I should say, not just adults, but adolescents as well. There are various sort of criteria and guidelines that have been put out there, which I generally find to be overly conservative and problematic.

Valerie Earnshaw: 14:51

So the guidelines are, cause I have them right in front of me. So they are"HIV negative, plus have had anal or vaginal sex in the past six months, plus have a sexual partner with HIV, or is someone who doesn't consistently use condoms, or someone who has been diagnosed with an STD in the past six months." So that's, that's like the sexual transmission route. And then for people who inject drugs, it's"if you have an injection partner, so you're sharing needles with someone who has HIV or if you kind of generally share injection equipment. So maybe you're sharing, you know, needles or injection equipment with someone who has HIV." So, okay. So those criteria for who is eligible to PrEP sound rather conservative to you. So please, please tell me why they sound conservative.

Dr. Sarah Calabrese: 15:38

Yeah. So I think my concerns, there's two ways of thinking about it. So one is how the criteria are used and then another is what they actually are. So in terms of how they're used, whether or not it was the intention, I think a number of clinicians use them as guidelines, to determine who to talk about PrEP with. And so, you know, to the extent they are unaware of patient's behavior, or patients' needs, or patients behavioral goals, like they may or may not be talking to a given patient, even though the patient could potentially benefit. In terms of what is actually in the criteria. We know that past behavior does not necessarily predict future behavior. And so the fact that somebody has had condom-less sex with a partner of unknown status multiple times in the last six months doesn't mean anything about the next six months or their plans for the next six months. So I think using past behavior as an indicator can be problematic. I think it also warrants consideration, the fact that this is really private, sensitive information about a patient that you are potentially asking about or thinking about. And so patients may or may not provide that information to their providers. Understandably so, and they may not be motivated to share intimate details of their sex life when they don't realize that being informed about PrEP is contingent on their doing so, like they may not really perceive a benefit in sharing that information with their provider. And so I think that having the provider be the decision maker about who gets to hear about PrEP, that is a problem. And I think that the criteria themselves, there are somewhat complicated. They depend on individual level behavior. It's been shown that this can actually lead to disparities in terms of who's eligible. So for example, black Americans have been less likely to be deemed eligible than white Americans in some studies. And that may be because their risk factors being less about individual level behavior and more about sort of networks or communities. I think the criteria that had been used are in need of reform, but I will also say the CDC is reforming those guidelines.

Valerie Earnshaw: 18:00

I didn't know about that.

Dr. Sarah Calabrese: 18:00

I recently learned about it. So there are draft guidelines that are posted online and there are webinars where they are inviting public comment next week, who knows what the next edition or iteration might be. But I did note in the draft that they were suggesting, talking about PrEP with all sexually active adults. So that's a step in the right direction. I'd still like to see some changes with that, but it's better than what we have already. So perhaps they're evolving.

Valerie Earnshaw: 18:29

Yeah. So one of the things we're kind of digging into a little bit this season, Sarah is around the intersection of like of scientists and policies. So, I mean, you were able to tell me exactly like when these meetings are so as a scientist, like, do you plan to get feedback? Do you plan to participate in these? Like, are you trying to share your expertise, with the CDC as they are- in a perfect world, they would come to you. Right. But, they don't usually come to us. So are you trying to like speak up based on your research,

Dr. Sarah Calabrese: 19:02

I plan to attend the meetings. There's a good chance. I will speak up though. I haven't planned exactly what I'm going to say. And I think it's important to attend these kinds of things. If you want to have an impact they're not accepting public comment otherwise, so that would be the place to do it. When the US preventative task force was developing their PrEP guidelines. I wrote a letter and outlined the reasons, that I thought that these criteria should be X, Y, and Z or changed. And I have made some small efforts in that respect, but I don't think that I've been consistent about contacting specific branch of the CDC with my ideas. You know, I publish on them, but I could probably do more.

Valerie Earnshaw: 19:41

No, but I mean, I think it's great even that you are writing letters that when the opportunity, when the CDC says,"Hey, we're listening", you're like,"All right, buckle up. I'm coming." I think that when there are opportunities, like what are you going to do drive to Atlanta? And, I don't know.

Dr. Sarah Calabrese: 19:58

That's crossed my mind.

Valerie Earnshaw: 20:01

This isn't, it's not really like part of our, part of our jobs. Like you're not going to, it's not going to count towards your promotion and tenure to talk about your advocacy work with the CDC. So anyway, I think that's awesome. I think it's great that you think about, you know, speaking up. Okay. So to take us back to some of these issues around why it's important to revise some of these guidelines, it seems like a lot of people who could benefit from PrEP, aren't actually receiving it. So some data that you shared with me before this recording was that there are estimated to be at least 1.8 million people in the US who would be eligible for PrEP, but only 18.1% of them have been prescribed it. So I, I continue to think that that's bananas. I mean, that's a pretty small like group of people who could benefit by this. And we're talking about benefiting from it, from these like conservative eligibility criteria. Right. So if we, if we've thought through that even more, there's probably like a lot more people who could benefit from, so the percentage of people getting it, who could, who could be helped from it is quite small,

Dr. Sarah Calabrese: 21:11

Right? Yeah. So it's probably the case that the percentage is much smaller than 18%. If you're taking into consideration the full gamut of people who could benefit from it. And I think that part of the reason for that is that it's not being made available to other people who could benefit from it. And there's still a lot of people who aren't aware of it. So you had actually shared that article with me, comparing awareness across different quote unquote risk groups. And, you know, indicated that even though something like 90% of MSM were aware of it, when I say MSM, men who have sex with men, I don't know if you've covered that already on your podcast, define that acronym. But by comparison, you know, it was something like a quarter of people who inject drugs were aware of it and a much smaller percentage of people who are heterosexual orientations, heterosexual activity, were aware of it. So like there's still a lot of unawareness that's out there and needs to be remedied.

Valerie Earnshaw: 22:12

Okay. So I'll, if we take all of these issues, what we end up seeing is so not only that, is there just not a lot of people who are accessing PrEP, but then when you take into like the provider bias and then some people haven't heard about it and all these other things, we also start to see a lot of disparities. So you also shared with me, you know, some, some work on those disparities. And I was really surprised, like I know that racial and ethnic disparities and health outcomes are everywhere, but this one really knocked me over. So of the folks who are sort of counted as eligible for PrEP of the white folks were counted as eligible 42% of them, according to the CDC data, the CDC data were accessing it, or, you know, had been prescribed it. But then for black folks, that was 6%. And for Latino folks, that was 11%. And I was just like, wow, this is so terrible. So we see racial and ethnic disparities. And then I also will highlight that there are, you know, just in the US there are a lot of disparities by geographic location. I was so surprised again, to see in Wyoming, it ranges from like 5% to New York where it's 41% of people who are eligible are receiving it, or, you know, are, have been prescribed, I suppose. I had to peak at at DC for you and Delaware. I mean, so DC, it's 37%, which I, of course described to you being in DC and working on it.

Dr. Sarah Calabrese: 23:40

Yes, totally appropriate.

Valerie Earnshaw: 23:44

And then in Delaware, it's 8.7%, which I prescribed to, or ascribed to our need in Delaware to get Sarah here, to work on PrEP.

Dr. Sarah Calabrese: 23:58

I like the way you think!

Valerie Earnshaw: 23:58

So, anyway, there's just, there's a lot of disparities even within this problem that not enough people are accessing it.

Dr. Sarah Calabrese: 24:07

Yeah. That is the case. And there's disparities in terms of who is accessing, but also who's aware of it, and also who providers are talking to about it. So there's also disparities in terms of whether or not they discussed with a provider and you see differences. So even though, you know, a high percentage of MSM are aware of PrEP, you see like racial disparities among MSM in terms of who's actually talking to them about it. So, so yeah, it's problem. And I think that it's a problem that could be helped by the sort of broader roll-out of PrEP and a more sort of inclusive messaging campaign. Because I think right now, it's just, it's very targeted and as a result, and it also relies a lot on provider discretion. And if we were to change some policies and change the messaging approach so that like everyone is being made aware of PrEP and even in a medical setting, everyone's being told about PrEP and then they can make informed decisions. I just think that would go a long way in terms of allowing more people to be aware of it and to pursue it.

Valerie Earnshaw: 25:18

Yeah. And you've written about this, that if we moved kind of more towards the models that we have for birth control and other things where it's like, this is a discussion that you have in primary care and your options are laid out. And I think you really hit on it earlier where the physician shouldn't be trying to look at you and you're out, like if you have had sex with someone living with HIV in the last six months, like ideally a provider should be saying like,"well, here's here is what it is here is who am I be useful for? What do you think?" And that's a much more, as you've pointed out in your writing, like it's a more patient centered approach and it's also sort of de-stigmatizing of PrEP.

Dr. Sarah Calabrese: 26:03

Right. So, I mean, I think if providers were talking about it with everyone, that would go a long way towards normalizing and de-stigmatizing, and I think that you hit on it when you said that, you know, it should really be the patient making informed choices. It's not up to the provider to decide like, what is best for their sex life or their relationship life. Like I believe that the provider's role is really more to form. Maybe help them talk through options and maybe help them to evaluate their risk,"them" being the patient, and then continue to care for them and provide support while they are taking PrEP. I don't think it needs to be more complicated than that. And I think that's, what's done with a lot of different types of preventative medication or, you know, different types of treatment. And so, like, it doesn't seem rational that we're not doing the same with HIV and PrEP.

Valerie Earnshaw: 26:52

Right. Right. Okay. So you teased this, we teased this a little bit earlier when we said that you ran this early study on providers and bias, and you found some evidence that bias might leak out to prescription of PrEP. That's a mouthful for every presentation you've ever given. Right. So can we talk a little bit more about your work unpacking this issue of what the provider biases might be specifically that are problematic, and how they might be sort of impacting whether, whether prescribers, it sounds like even like raise PrEP as an issue, or raise PrEP as an option with the patients that they're seeing?

Dr. Sarah Calabrese: 27:32

Yeah. I mean, so I can talk a little bit about the line of work, that or line of work that you've referenced. So the initial study that we did together, which I described somewhat previously, but it was with a small sample of medical students around a little over a hundred, and they were randomly assigned to read a clinical vignette that was either about a black patient or a white patient. Otherwise the clinical vignette was totally the same. It was about an MSM patient who was at risk for HIV because he was having condomless sex with his partner. He wanted a prescription for PrEP, and then they were asked to make a series of clinical judgment about that patient and ultimately indicate their intention to prescribe PrEP for him. And so what came out of that study and what we saw is that the black patient was judged as more likely to increase his sexual risk-taking if he was prescribed PrEP and that in turn was associated with a lower intention to prescribe. So this kind of suggests that we have this like indirect effect of race on protective access to PrEP. And so that prompted a couple of other experimental studies that were kind of in the same vein. So there was a followup study. We did again with medical students and we didn't see the same grace effect. And we didn't see racism. We also looked at or measured racism of the medical students, including both explicit, so meaning how they reported their attitudes on self-report measure, as well as implicit attitudes, we saw minimal impact of patient race, or medical student racism on clinical decision making related to PrEP. So, you know, it was inconsistent with the first study, but still like promising for society. Good news in that study that we also saw that heterosexism is associated with clinical judgments about the patient. And when I say hetero-sexism, I mean negative judgment of people who are sexual minorities. And so the more prejudice against sexual minorities, somebody was the more negative, the clinical judgment. And this was again, related to a reduced intention to prescribe PrEP to the individual. So as you know, we did a third study, which I was incorporating your comments on last night, but where we looked at practicing providers. And so this was primary care and HIV care clinicians throughout the US we changed the paradigm a little bit. So rather than having them read a vignette, we had them review medical charts and we manipulated key pieces of information in the chart. So again, we manipulated the race of the patient, but we also manipulated their misbehavior, why it was, they would be seeking a PrEP prescription. So in all cases, the patient was a male patient, but a male patient was either at risk because of sex with a woman living with HIV, sex with a man living with HIV, or because of sharing needles, being an injection drug user, and sharing needles with a partner who had HIV. And so what really came out of that third study was this bias related to people who inject drugs. So specifically, you know, in all cases, the patient was described as seeking a prescription for PrEP. The description was such that it was very clear. This would be a really good candidate for PrEP and it gave background information about PrEP. We talked about risk involved, like the relative risk of different types of behaviors in terms of HIV transmission, even though all of these candidates were really great candidates for PrEP and all of them were doing a pretty responsible thing because they were going to the healthcare provider asking for PrEP. We still saw some differences in how they were judged. So the patient who injected drugs was judged as being less responsible, less safety conscious, and less likely to adhere to PrEP if given a prescription for PrEP. And then we saw that some of these judgments were again, related to lower intention to prescribe to the patient. So I would say collectively these three studies suggest that really, I mean, they're all experimental in nature, so they're not documenting sort of real life bias and its impact, but we specifically use an experimental approach. So we could really isolate different forms of bias. And I would say collectively, they suggest that provider social biases can influence clinical decision making related to PrEP.

Valerie Earnshaw: 32:10

Yeah. And when, whether or not someone hears about PrEP, has the opportunity to learn about PrEP, and has the opportunity for PrEP to be offered to them, hinges on whether the provider raises it in that clinical encounter. If they're assuming that the person is going to engage in more risky sex, because they're a black man, as opposed to a white man. And or if they think that this person who injects drugs is going to be as adherent to PrEP as a person who doesn't inject drugs- which just by the way, Chinazo Cunningham, who works a great deal with people who use drugs. And she always brings up that drug users are good at using drugs.

Dr. Sarah Calabrese: 32:54

Yeah. Nicely worded.

Valerie Earnshaw: 32:57

Uh, in some studies, you know, and we have some evidence that people who inject people who use drugs, aren't less adherent to their HIV medication, other things, because they're good at using drugs. But anyway, all of these like ideas, these perceptions that providers have, because providers are just people who like the same stereotypes and ideas as everyone else that if it all rests on them, that, yeah, it's just, it's a problematic piece where the step of getting PrEP to people is just, could just fall apart. So

Dr. Sarah Calabrese: 33:30

And it does fall apart. Yeah, exactly. And I'm glad that you pointed out that providers are just people, because I think sometimes when I'm talking about provider biases, I feel like I'm villainizing providers, when in actuality we all have biases and you know, they're no different in that respect. And so, I think that what we want to do is implement policies and strategies that can help to either reduce those biases or mitigate their effect on their mental decision-making. So, if we are allowing provider discretion to dictate who is told about PrEP, and particularly given that PrEP is a situation where there is provider discretion involved and therefore the best course of action might be somewhat ambiguous. That's where biases- that opens the door to personal biases. Whereas if we were telling providers,"Listen just talk to everyone about PrEP and, you know, support them in making their decision" then they're not saying,"Hmm, this person's risky. This person's not, this person's going to have an adherence problem". It takes the burden off them, it like makes PrEP more accessible. And it also, I mean, that is a stressor, I think for providers, not necessarily to think that they have bias, but to determine the eligibility, that's something that has come up in research about barriers to PrEP provision is, you know, concerns about determining who is eligible for PrEP. And so if we just kind of shifted it, so it's like, apart from these medical indications or Contra-indications, like everyone is eligible, so just support them in making their decision. I think that could go a long way.

Valerie Earnshaw: 35:10

That's really helpful to hear that, like this sort of stresses providers out, like, of course it would, you know, that makes total sense to me that like the burden of having to figure out who's eligible, who's not, who may not feel comfortable sharing like information about eligibility, like what kind of sex t hey've been having or who they've been having it with or who they've been sharing needles with. Like people may, people may not want to share that with their family doctor or if they're an adolescent, like their pediatrician or things like there's so many reasons and doctors want to help people. Right. And so, yeah, that's a really interesting perspective to feel like that's a burden and yeah. I mean, as a woman, I, when I go through routine like h ealthcare now, it's like, I feel like I went in maybe for a bone scan. And I think I was asked by like three different people if I experience domestic violence, you know, just because they're starting to ask everybody, like, have you experienced this? Just because there's lots of reasons why people wouldn't want to tell their providers or w ouldn't raise it, that they've experienced it. And they're not going to be able to look at me and tell somehow that I would be someone w ho's at risk of that. So they're just, it's just a blanket policy, you know? So enacting o r sort of following some of those strategies within this arena could be really beneficial.

Dr. Sarah Calabrese: 36:34

Yeah. I mean, I think you're speaking to the fact that like even an individual, they can only predict their own risk to some extent. Right. Um, but they are better at doing that than their provider. Like really an individual is the expert when it comes to their own sexual lives, and their plans, and like predicting whether or not they're going to be... really, they should be the ones making the judgment call. And, you know, also when it comes to disclosing sensitive information, it's easier, and I think that you alluded to this, it's easier to disclose some behaviors than others. So as a heterosexual woman, like disclosing sex with a man that can be awkward, I don't have to worry about being discriminated against for my sexual orientation. Right. And so it's the case that like somebody who has a man who has sex with men, like here's a huge, additional hurdle that they have to take a much bigger risk in sharing that information with a provider, because they don't know how the provider could react. And if you think about sort of intersectionality, right? Like a black MSM has even more challenges, you know, that they have like additional pressure because they already feel like a medical provider may judge them based on their sex or their race and men disclosing this other minority status could seem like an additional risk. And so I, again, I think that I almost feel like risk behaviors shouldn't have to be disclosed. So let me sort of qualify that a little bit. Like, I think that in many cases it is helpful for a provider to know about risk you're taking so that they can help care for you and like tailor their care and treatment depending on what you disclosed. But when it comes to PrEP, it seems to make more sense to me to just say like,"listen, this is what PrEP protects against. This is how it could be beneficial. Do you think that you could benefit from it? Do you want to pursue it?" And then if the patient wants to like delve into, well,"I'm having sex with a man and a woman" that's their business and they could disclose that and maybe that will help with other aspects of care, but when it comes to just like, who should access PrEP and who's not, it isn't the case that like only men who have sex with men are only like everybody who has sex and could benefit from PrEP. So like, why are we making these distinctions or like forcing patients to make those uncomfortable disclosures.

Valerie Earnshaw: 39:07

Yeah. Okay. Sarah. Well, I would be really remiss if I let you out of this podcast recording without bringing up sexual pleasure. So, when I read your writing about PrEP, especially, you know, you had this really lovely commentary in the American journal of public health about PrEP and stigma. You write quite a bit about sexual pleasure and every time I read it, I'm like, oh yeah, nobody is talking about sexual pleasure and PrEP. So I just wanted to pick your brain a little bit around why is sexual pleasure left out of the conversation around PrEP and why is it important to bring it up?

Dr. Sarah Calabrese: 39:51

Yeah. So thank you for your kind words about my commentary. Yeah. In terms of why it's not discussed more. So, I mean, I think in general, when we think about science and scientific discourse, there's much more of an emphasis on kind of pathology and disease prevention than there is about kind of more positive dimensions of sexual health and wellbeing. So I think that, you know, there has been an emphasis on protection against HIV without a kind of corresponding recognition of the benefits to sexual health, the form of pleasure and other types of central social benefits. Pleasure is important because it's an aspect of sexual health and sexual health is important because it's part of our whole health. And so it's something that I think we should be talking about. We don't do it enough. And it's important. I think in the case of PrEP, because it can incentivize PrEP use, that's a good thing, right? It can help people recognize the benefit of PrEP for them and then have more fulfilling sexual lives. And, you know, not just in terms of pleasure in terms of like physical sensation, but also like in terms of feeling intimacy, feeling less anxiety, some more enjoyment during sex. And also it might open up relationship possibilities for people who have previously avoided different relationships, avoided being in relationships with people who are living with HIV because of fear of transmission. Like this can make them more comfortable and this can make it less of an issue in couples where one person has HIV and the other person doesn't. So like there's so many and pleasure is so important. And, you know, I think that we need to change the paradigm a little bit, but I, I think that part of it is something that should be driven from the top in terms of when it comes to funding. And when it comes to scientific journals. They should be making this more of a priority. So I was thrilled to see a couple of years ago, the American journal of public health did kind of a special section about pleasure and how that was important to health. And so, you know, they made that something that they demonstrated that that was something that's important issue and a priority to them. And I think when it comes to funding, for example, a lot of researchers go to the national institutes of health and it would be great if they put out a call for research that focused on enhancing sexual pleasure, instead of just like, oftentimes it seems more about disease prevention. And so it would be great if there was kind of a change in thinking at the top, because I think that could also filter down in terms of the science that we actually do and the research questions that we strive to answer.

Valerie Earnshaw: 42:43

Absolutely. Oh, Sarah, you're such a great example of someone I think, who feels really passionately about an area and someone who has really focused on trying to understand a problem what's happening with that problem. And then identifying very doable solutions. I think that this is so important because there are so many disparities, you know, when it comes to PrEP and there's just so much work that needs to be done when only 18%, but probably a lot fewer people who are eligible for PrEP or who could benefit from PrEP are actually accessing it. It's a huge problem. So just want to say, thank you for all the excellent work you're doing in this area. Thank you for having me along for some of that work. And in particular, thank you today for coming on and talking with us about it.

Dr. Sarah Calabrese: 43:39

Well, thank you so much for having me on, I really appreciate you drawing attention to this issue and some of my work and thank you for all your contributions to the research that we've done together. I'm looking forward to continuing to collaborate on that stuff.

Valerie Earnshaw: 43:52

You're so nice. Cause you always refer to it as the work we're doing together, but I want every listener to know that this is like Sarah Calabrese, and like Valerie back in the wing. So it's really generous that you've included me and I love working on it with you and thinking about it. So thank you. Thank you. Thanks to the Stigma and Health Inequities Lab at the University of Delaware for their help at the podcast, including Saray Lopez, Molly Marine, James Wallace, and Ashley Roberts.

Carly Hill: 44:20

Thanks to city girl for the music as always be sure to check us out on Instagram@sexdrugsscience, and stay up to date on new episodes by clicking subscribe.

Valerie Earnshaw: 44:28

Thanks to all of you for listening.[inaudible].