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. Author manuscript; available in PMC: 2025 Jan 27.
Published in final edited form as: Arch Sex Behav. 2022 Jun 10;51(5):2535–2547. doi: 10.1007/s10508-022-02337-0

Willingness to prescribe PrEP to bisexual men depends on genders of their past partners: A study of medical students in the U.S.

Brian A Feinstein 1, Cindy J Chang 2, Samuel R Bunting 3, Jesse Bahrke 1, Aniruddha Hazra 4, Sarah S Garber 5
PMCID: PMC11770352  NIHMSID: NIHMS2045273  PMID: 35689147

Abstract

Bisexual men are at increased risk for HIV compared to heterosexual men but unlikely to use pre-exposure prophylaxis (PrEP). Given that biases may influence whether bisexual men are prescribed PrEP, we examined whether medical students’ decision-making was influenced by the genders of a bisexual male patient’s partners. Medical students (N=718) were randomized to one of nine conditions where they answered questions about a bisexual male patient after reviewing his electronic medical record. We manipulated the gender of his current partner (none, male, female) and the genders of his past partners (male, female, both). Current partners were described as living with HIV and not yet virally suppressed, past partners were described as being of unknown HIV-status, and condom use was described as intermittent with all partners. When the patient was not in a current relationship, perceived HIV risk and likelihood of prescribing PrEP were lowest if he only had female partners in the past. When he was in a current relationship, perceived HIV risk and likelihood of prescribing PrEP did not differ based on current or past partners’ genders. In addition, identification as a PrEP candidate, perceived likelihood of adherence, and perceived likelihood of engaging in condomless sex if prescribed were lower when the patient was not in a current relationship. Medical students appropriately prioritized the status of the partner living with HIV, but their decision-making was influenced by past partner genders when the patient was not in a current relationship. Medical students may require additional education to ensure they understand PrEP eligibility criteria and make decisions based on patients’ individual presentations.

Keywords: HIV prevention, PrEP, medical students, bisexual, partner gender

Introduction

In the United States, the field of HIV prevention has primarily focused on gay men, or men who have sex with men (MSM) as a broad category, with limited attention to bisexual men in particular (Feinstein & Dodge, 2020). Despite the relative lack of research on HIV among bisexual men, the available evidence indicate that bisexual men are at increased risk for HIV compared to heterosexual men, but they are at decreased risk compared to gay men (Caceres et al., 2018; Friedman, Dodge, et al., 2014; Friedman, Stall, et al., 2014; Friedman, Wei, et al., 2014). For example, a meta-analysis of U.S. studies found that men who have sex with both men and women were five times more likely to be living with HIV as men who have sex with women only, but they were half as likely to be living with HIV as men who have sex with men only (Friedman, Wei, et al., 2014). Similarly, a recent U.S. study found that self-identified bisexual men were at increased risk for HIV compared to self-identified heterosexual men who had never had sex with men (7.7% vs. 0.3%), but they were at decreased risk compared to self-identified gay men (17.4%) (Caceres et al., 2018). Although both gay and bisexual men are at increased risk for HIV compared to heterosexual men, bisexual men are less likely than gay men are to routinely get tested for HIV and they are less likely to use pre-exposure prophylaxis (PrEP) for HIV prevention (Feinstein, Dodge, et al., 2019; Feinstein, Moran, et al., 2019; Grov et al., 2016; Jeffries, 2010; Jin et al., 2002). PrEP is highly effective for HIV prevention (up to 99% efficacy with daily dosing) (Mayer, Molina, et al., 2020; Owens, 2019), but as of 2019, only an estimated 35% of the nearly 1.4 million MSM in the U.S. with indications for PrEP were using this essential HIV prevention method (Bates et al., 2021; Finlayson et al., 2019; Mayer, Agwu, et al., 2020). However, it is unknown how many bisexual men with indications for PrEP are using it. Further, prescription remains particularly low among populations disproportionately affected by HIV (e.g., people of color, transgender women) (Kamitani et al., 2020). While there has been increased attention to the need to scale-up PrEP in specific populations, bisexual men continue to be left out of these conversations (Feinstein & Dodge, 2020).

Barriers to PrEP Scale-Up

Numerous barriers to the overall scale-up of PrEP have been identified, such as limited awareness and knowledge of PrEP among U.S. clinicians (Mayer, Agwu, et al., 2020; Pleuhs et al., 2020; Smith et al., 2016; Wood et al., 2018), PrEP-related stigma (Dubov et al., 2018; Mayer, Agwu, et al., 2020; Thomann et al., 2018), provider concern that patients will increase their engagement in sexual risk behavior (e.g., condomless sex) if prescribed PrEP (Blumenthal & Haubrich, 2014; Pleuhs et al., 2020), and logistical barriers (e.g., cost, health insurance access) (Felsher et al., 2018; Marcus et al., 2019). With respect to knowledge, a number of specific gaps have been identified among clinicians in the U.S., including not being familiar with guidelines for PrEP prescription and management (Smith et al., 2016; Wood et al., 2018). In fact, one study found that nearly 40% of U.S. patients who were denied PrEP by a healthcare provider were denied because the provider was unsure how to prescribe it (Furukawa et al., 2020). Further, U.S. clinicians have identified a need for additional training in PrEP prescription and management, including how to identify which patients are candidates for PrEP (Bleasdale et al., 2020; Rao et al., 2021). These gaps in knowledge also extend to future clinicians (i.e., medical students) and are perpetuated as medical students move into professional roles. For example, prior studies have found that over one-third of fourth-year medical and pharmacy students in the U.S. have not received training in PrEP (Bunting, Garber, Goldstein, Ritchie, et al., 2020). and nearly half of medical and pharmacy students in the U.S. are not knowledgeable about which medications are approved for PrEP, the recommended HIV testing frequency for patients taking PrEP, and contraindications to use (Bunting, Feinstein, Hazra, Sheth, et al., 2021; Przybyla et al., 2019, 2021).

Given that PrEP requires a prescription, clinicians’ ability to identify eligible patients is a major factor influencing access. In fact, accumulating evidence suggests that provider biases have an influence on their willingness to prescribe PrEP (Calabrese, 2020; Mayer, Agwu, et al., 2020; Pleuhs et al., 2020.) For example, clinicians who prescribe PrEP have described how other providers refuse to prescribe PrEP because of their own personal values related to sex and discomfort discussing sex with patients (Calabrese et al., 2019). Further, several studies have found that physicians are more likely to prescribe PrEP to HIV-serodifferent couples than to single MSM (Adams & Balderson, 2016; Smith et al., 2016). This may reflect biased beliefs that using PrEP in an HIV-serodifferent relationship reflects a necessary precaution, whereas using PrEP as a single person reflects a choice to engage in condomless sex. Given that provider biases can influence decisions about who to prescribe PrEP to, it is possible that providers’ beliefs about bisexual men play a role in their access to PrEP.

The Role of Patient Sexual Orientation in PrEP-Related Clinical Decision-Making

To our knowledge, only one prior study has examined the role of patient sexual orientation (including bisexuality) in clinicians’ or medical students’ perceptions of patients’ HIV risk and indication for PrEP (Bunting, Feinstein, Hazra, & Garber, 2021). In that study, U.S. medical students were randomly assigned to review vignettes about fictional patients (who varied in gender identity and sexual orientation) who were described as engaging in condomless sex with partners of unknown HIV-status. There were no significant differences in perceived HIV risk, perceived indication for PrEP, or assumptions about the patient’s behavior if prescribed PrEP (e.g., adherence, engagement in condomless sex) for the gay versus bisexual male patient. These findings are promising as they suggest that medical students are treating gay and bisexual male patients the same with respect to decisions about PrEP. However, this prior study did not allow for comparisons of bisexual men with partners of different genders, and there is evidence that bisexual men’s experiences differ as a function of the gender of their partners (e.g., bisexual men with male partners are more open about their sexual orientation and experience more discrimination than bisexual men with female partners) (Feinstein et al., in press). To address this limitation, the goal of the current study was to examine whether the genders or a bisexual man’s partners influence medical students’ assumptions and decisions related to HIV risk and PrEP prescription.

Bisexual men contend with a number of unique stereotypes, many of which are related to their sexual behavior (Feinstein & Dyar, 2017). People generally assume that bisexual men are gay and afraid to come out “all the way,” they are stereotyped as being promiscuous and unable to commit to one partner, and they are believed to “bridge” HIV from the gay community to their female partners—a claim with scant empirical support (Feinstein & Dodge, 2020; Feinstein & Dyar, 2017). Given these stereotypes, particularly the belief that bisexual men are actually gay, the lack of significant differences between the gay and bisexual male patient conditions in the previously described study may have been due to the medical students perceiving the bisexual male patient as actually being gay (Bunting, Feinstein, Hazra, & Garber, 2021). Previous research has also found that bisexual men with female partners are less likely to disclose their sexual orientation than those with male partners (Feinstein et al., in press). As such, it is possible that providers are less likely to consider a bisexual man as a candidate for PrEP if they are in a relationship with a female partner or have only had female partners in the past.

The Current Study

To address the lack of research on clinical decision-making regarding PrEP prescription for bisexual men, the goals of the current study were to examine whether medical students’ judgements and decision-making related to HIV risk and PrEP prescription for a bisexual male patient were influenced by the genders of his partners. To test this, we presented medical students with a fictional electronic medical record (EMR) describing a bisexual male patient and we manipulated the genders of his past partners (male, female, or both). Across conditions, the patient was described as having engaged in intermittent condom use with partners of unknown HIV-status. We also manipulated whether he was in a current relationship with a partner living with HIV (male or female) or not in a current relationship. Consistent with previous research (Calabrese et al., 2014, 2018), when the patient as described as being in a current relationship, the partner was describe as living with HIV and not yet virally suppressed, and they were described as engaging in intermittent condom use, to indicate HIV risk. Of note, across conditions, the information provided indicated that the patient was a candidate for PrEP based on the CDC’s clinical practice guidelines (CDC, 2018). We hypothesized that current and past partner genders would interact in the following ways:

  1. When the patient was not in a current relationship, participants would be least likely to rate the patient who only had female partners in the past as a candidate for PrEP and they would be least likely to prescribe him PrEP (compared to the patient who only had male partners in the past and the patient who had both male and female partners in the past). We considered the comparisons between the patient who only had male partners in the past and the patient who had both male and female partners in the past to be exploratory given competing possibilities. On the one hand, participants may be more likely to rate the patient who only had male partners in the past as a candidate for PrEP and more likely to prescribe him PrEP because he may be perceived as having sex with higher risk partners (i.e., only MSM). On the other hand, participants may be more likely to rate the patient who had both male and female partners in the past as a candidate for PrEP and more likely to prescribe him PrEP because his behavior may be perceived as more consistent with stereotypes of bisexual men as promiscuous and as “bridging” HIV from male to female partners (Feinstein & Dodge, 2020; Feinstein & Dyar, 2017).

  2. Similarly, when the patient was not in a current relationship, participants would rate the patient who only had female partners in the past as being at lowest risk for HIV, as least likely to adhere, and as least likely to engage in condomless sex if prescribed (compared to the patient who only had male partners in the past and the patient who had both male and female partners in the past). Again, we considered the comparisons between the patient who only had male partners in the past and the patient who had both male and female partners in the past to be exploratory.

  3. When the patient was in a current relationship with a partner living with HIV (male or female), the HIV-status of the partner would take precedence over the genders of the patient’s current and past partners, such that neither current nor past partner genders would influence perceptions of whether the patient was a candidate for PrEP, willingness to prescribe PrEP, perceptions of HIV risk, or assumptions about the patient’s behavior if prescribed PrEP.

Method

Participants and Procedure

The current analyses used data from a larger project focused on medical students’ knowledge, decision-making, and biases related to PrEP. Data were collected from March through May 2021. Participants were recruited from 16 medical schools (10 allopathic, 6 osteopathic) in the U.S. with a combined enrollment of 12,660 students. Potential participants were emailed a description of the study and a link to a brief eligibility survey. In an effort to limit selection bias, the study was not described as being focused on HIV, PrEP, or bisexuality in the recruitment message. Students who met the inclusion criteria (age 18+ and currently studying in an allopathic or osteopathic medical education program) were sent a follow-up email with a link to the study, which was hosted on Qualtrics. Following informed consent, participants were randomized to one of nine experimental conditions (described below) via Qualtrics. The randomization algorithm was programmed to ensure a balanced number of participants in each of the nine conditions. After completing the study, participants were given a $10.00 credit to an online retailer and sent a debriefing message. The study was approved by the Institutional Review Board at Rosalind Franklin University of Medicine and Science.

Measures

Before launching the study, a focus group consisting of five medical students from a single allopathic medical school completed the study and provided feedback on the materials (e.g., vignettes, follow-up items). Minor edits were made based on their feedback.

The first section of the study was a vignette describing a fictional bisexual male patient presenting to a primary care physician inquiring about PrEP. We systematically varied the genders of the patient’s past partners (male, female, both) and the gender of his current partner (none, male, female) in a 3×3 factorial design. All vignettes were presented in the format of a simulated EMR (see Figure 1 for an example), which contained the reason for the visit and clinical information. Laboratory results, including a negative HIV antigen/antibody test, were included, as well as normal vital signs and past medical history. All patients were described as being in overall good health without significant medical or surgical history. Across conditions, all vignette information was identical with the following exceptions (i.e., the experimental manipulations):

Figure 1.

Figure 1.

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Example of simulated electronic medical record.

Conditions 1–3 (not in a current relationship).

For these three conditions, the patient was described as “…having had 4 sexual partners over the past year. His partners have been [all men/all women/both men and women], and he reports intermittent condom use. He is unaware of his partners’ HIV statuses.”

Conditions 4–9 (in a current relationship).

For these conditions, the reason for visit stated, “He reports that he is in a new monogamous relationship with a [male/female] partner who is HIV-positive. His partner recently began HIV treatment but is not yet virally suppressed. He reports intermittent condom use. When reviewing his sexual history, he reports having had 4 sexual partners [all men/all women/both men and women] over the past year prior to beginning his current relationship.”

Following the vignette, participants responded to a series of follow-up items regarding the presented patient: 1) Is the patient a candidate for HIV pre-exposure prophylaxis (PrEP)? (yes or no); 2) How likely would you be to prescribe PrEP to this patient? (1 = extremely unlikely, 7 = extremely likely); 3) How high is the patient’s HIV risk? (1 = extremely low, 7 = extremely high); 4) If prescribed PrEP, how likely is it that the patient would adhere to the medication? (1 = extremely unlikely, 7 = extremely likely); and 5) How likely is this patient to have condomless sex if prescribed PrEP? (1 = extremely unlikely, 7 = extremely likely).

Next, participants completed a brief (5-item) assessment of PrEP knowledge developed for the current study. The assessment included a combination of true/false and multiple-choice questions: 1) “PrEP cannot be prescribed to prevent HIV for anal sex” (correct answer: false); 2) “PrEP cannot be prescribed to prevent HIV from vaginal sex” (correct answer: false); “With daily dosing (7 doses per week), how effective is PrEP at preventing new HIV infections?” (response options: 50%, 75%, 90%, and >99%; correct answer: >99%); 4) “Which of the following medications is FDA-approved for use as PrEP for HIV prevention?” (response options: Lamivudine [Epivir®], Efavirenz [Sustiva®], Emtricitabine [Emtriva®], Tenofovir [Viread®], and Emtricitabine/Tenofovir [Truvada®]; correct answer: Emtricitabine/Tenofovir [Truvada®]); and 5) “Which of the following lab results are required before a patient can begin PrEP? (response options: normal thyroid hormone levels, HIV-1 negative test, fasting blood glucose < 100 mg/mL, and creatinine clearance ≥ 60 mL/min; correct responses: HIV-1 negative test and creatinine clearance ≥ 60 mL/min). The first four items were scored as 0 (incorrect) and 1 (correct). The fifth item had two correct answers and each was scored as 0 (incorrect) and 1 (correct). We created percent correct scores by averaging responses across items and multiplying the resulting values by 100. Finally, after completing the follow-up items, participants provided demographic information.

Analytic Plan

Analyses were conducted in SPSS Version 28. First, we conducted preliminary analyses to test the success of our randomization procedure. We used chi-squared analyses (for categorical variables) and one-way analyses of variance (for continuous variables) to test whether demographics (age, gender, sexual orientation, race, program type, and program year) and PrEP knowledge differed by condition. Then, we conducted Pearson and point biserial correlations to examine the associations among our variables of interest. Finally, for our primary analyses, we conducted a series of generalized linear models (one for each outcome) to examine the effects of current partner gender (male, female, or none), past partner genders (male, female, or both), and their interaction on our outcomes of interest (PrEP candidacy, likelihood of prescribing PrEP, perceived HIV risk, perceived likelihood of adherence to PrEP, and perceived likelihood of engaging in condomless sex if prescribed PrEP). Model-based pairwise contrast effects with estimated marginal means were used to probe differences in outcomes by current partner gender, past partner genders, and their interaction. Effect sizes (Cohen’s d) are presented for significant pairwise contrast effects (0.2 = small effect, 0.5 = medium effect, 0.8 = large effect) (Sullivan & Feinn, 2012). All analyses controlled for participant age, gender, sexual orientation, race, program type, and program year.1

Results

Demographics

Of the 1,592 students who expressed interest in the study and met the inclusion criteria, 808 (50.8%) went on to initiate it and 718 completed it. The number of participants randomized to each of the nine conditions ranged from 71 to 90. Participants ranged in age from 19 to 50 (M = 26.25, SD = 3.25). Full demographic characteristics of the sample are presented in Table 1.

Table 1.

Description of sample demographics (N = 718).

Variable % N
Gender
 Cisgender man 35.9 258
 Cisgender woman 62.3 447
 Transgender/non-binary 1.8 13
Sexual orientation
 Heterosexual 84.1 604
 Gay/lesbian 5.6 40
 Bisexual 7.4 53
 Not listed 2.6 19
Race
 White 53.9 387
 Latinx 4.2 30
 Black 2.8 20
 Asian 30.1 216
 American Indian/Alaskan Native 0.3 2
 Not listed 2.4 17
 Biracial/Multiracial 6 43
Academic program
 Allopathic/MD 53.2 382
 Osteopathic/DO 46.8 336
Program year
 1st year 28.4 204
 2nd year 26.3 189
 3rd year 21.9 157
 4th year 23.4 168
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Note: Given low frequencies in some demographic groups, sexual orientation was recoded into two categories for analyses (heterosexual and non-heterosexual) and race was recoded into three categories for analyses (white, Asian, and other race).

Preliminary Analyses

Participant demographics did not differ between the nine experimental conditions. Chi-squared analyses demonstrated that condition was not significantly associated with gender, sexual orientation, race, program type, or program year (ps ranged from .24 to .48). A one-way analysis of variance (ANOVA) demonstrated that participant age did not differ across conditions, F(8, 708) = 1.14, p = .34. Means, standard deviations, and zero-order correlations are presented in Table 2. Most variables of interest were significantly associated with one another in the expected directions. The only exceptions were that rating the patient as a candidate for PrEP was not significantly associated with perceived likelihood of adherence or perceived engagement in condomless if prescribed PrEP (ps > .27). PrEP knowledge ranged from 0–100% (Mean = 74.14, Mode = 83.33, SD = 21.91). Most participants (83.1%) got at least two-thirds of the PrEP knowledge questions correct, and few participants (8.4%) got less than half correct. A one-way ANOVA demonstrated that PrEP knowledge did not differ across conditions, F(8, 709) = 1.01, p = .43.

Table 2.

Pearson’s and point biserial correlations for variables of interest.

1. 2. 3. 4. % or M (SD)
1. PrEP candidate - - - - 91.5%
2. Likelihood of prescribing PrEP .53*** - - - 6.00 (1.19)
3. Perceived HIV risk .22*** .48*** - - 5.69 (1.07)
4. Perceived likelihood of engaging in condomless sex .03 .20*** .30*** - 5.06 (1.13)
5. Perceived likelihood of adherence to PrEP .04 .41*** .25*** .14*** 5.78 (1.00)
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*

p < .05

**

p < .01

***

p < .001 level

PrEP candidate was rated as yes or no; all other items were rated on 1–7 scales.

Main and Interaction Effects

Pairwise comparisons for current and past partner gender are presented in Table 3, and pairwise comparisons for their interaction are presented in Table 4.

Table 3.

Estimated marginal means for main effects of current and past partner genders.

Current partner gender
M (SD)		 Past partner gender
M (SD)
None Male Female Male Female Both
PrEP candidate .90 (.63) .97 (.24) .96 (.31) .95 (.33) .92 (.51) .96 (.28)
Likelihood of prescribing PrEP 5.53 (1.91) 6.28 (1.85) 6.17 (1.90) 6.16 (1.92) 5.79 (1.88) 6.01 (1.87)
Perceived HIV risk 5.05 (1.77) 5.60 (1.72) 5.59 (1.76) 5.58 (1.77) 5.17 (1.74) 5.49 (1.72)
Perceived likelihood of engage in condomless sex 4.84 (1.97) 5.13 (1.93) 5.07 (1.98) 5.08 (2.01) 4.96 (1.96) 5.00 (1.91)
Perceived likelihood of adherence to PrEP 5.42 (1.67) 5.66 (1.64) 5.62 (1.69) 5.65 (1.70) 5.45 (1.66) 5.61 (1.64)
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Notes: All analyses controlled for participant age, gender, sexual orientation, race, program type, and program year.

Table 4.

Estimated marginal means for interactions between current and past partner genders.

Current partner gender None Male Female
Past partner gender Male Female Both Male Female Both Male Female Both
PrEP candidate .92 (.40) .77 (.71) .94 (.28) .96 (.21) .96 (.22) .98 (.14) .97 (.18) .96 (.24) .95 (.28)
Likelihood of prescribing PrEP 5.95 (1.46) 5.02 (1.38) 5.61 (1.39) 6.26 (1.40) 6.34 (1.40) 6.23 (1.37) 6.28 (1.39) 6.02 (1.42) 6.20 (1.42)
Perceived HIV risk 5.41 (1.35) 4.65 (1.28) 5.08 (1.28) 5.53 (1.30) 5.59 (1.29) 5.69 (1.26) 5.80 (1.29) 5.27 (1.31) 5.69 (1.31)
Perceived likelihood of engage in condomless sex 4.84 (1.51) 4.87 (1.43) 4.82 (1.44) 5.26 (1.45) 5.05 (1.45) 5.08 (1.41) 5.13 (1.44) 4.96 (1.47) 5.11 (1.48)
Perceived likelihood of adherence to PrEP 5.46 (1.28) 5.22 (1.22) 5.59 (1.22) 5.75 (1.24) 5.69 (1.22) 5.55 (1.20) 5.72 (1.23) 5.45 (1.25) 5.69 (1.25)
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Notes: Means are outside of parentheses and standard deviations are inside of parentheses. All analyses controlled for participant age, gender, sexual orientation, race, program type, and program year.

PrEP candidacy.

The main effect of current partner gender on PrEP candidacy was significant (Wald Chi-Square = 13.48, p = .001). Pairwise comparisons indicated that when the patient was not described as being in a current relationship, participants were less likely to identify them as a PrEP candidate compared to when the patient currently had a male (p = .03, d = .15) or female (p = .04, d = .12) partner living with HIV. PrEP candidacy did not differ by whether the patient currently had a male or female partner living with HIV (p = .52). The main effect of past partner gender and the interaction between current and past partner gender on PrEP candidacy were not significant (ps > .15).

Likelihood of prescribing PrEP.

The main effects of both current partner gender (Wald Chi-Square = 66.22, p < .001) and past partner gender (Wald Chi-Square = 14.62; p = .001) on likelihood of prescribing PrEP were significant. Pairwise comparisons indicated that when the patient was not described as being in a current relationship, participants were less likely to prescribe PrEP to the patient compared to when the patient currently had a male (p < .001, d = .40) or female partner living with HIV (p < .001, d = .34). Likelihood of prescribing PrEP did not differ by whether the patient currently had a male or female partner living with HIV (p = .27). Additionally, participants were less likely to prescribe PrEP to the patient when he only had female partners in the past compared to when he only had male partners in the past (p < .001, d = .19) or when he had both male and female partners in the past (p = .03, d = .12). Likelihood of prescribing PrEP did not differ when patients had only male versus both male and female partners in the past (p = .13).

There was also a significant interaction between current and past partner gender on likelihood of prescribing PrEP (Wald Chi-square = 19.11, p = .001). When the patient was not described as being in a current relationship, participants were less likely to prescribe PrEP to the patient who only had female partners in the past compared to the patient who only had male partners in the past (p < .001, d = .65) or who had both male and female partners in the past (p = .001, d = .43). Participants were also less likely to prescribe PrEP to the patient who had both male and female partners in the past compared to the patient who only had male partners in the past (p = .049, d = .24). In contrast, when the participant was in a current relationship with a male or female partner living with HIV, likelihood of prescribing PrEP did not differ based on past partner gender (ps > .12).

Perceived HIV risk.

The main effects of both current partner gender (Wald Chi-Square = 47.80, p < .001) and past partner gender (Wald Chi-Square = 22.10; p < .001) on perceived HIV risk were significant. Pairwise comparisons indicated that the patient who was not in a current relationship was perceived as being at lower risk for HIV compared to the patient currently in a relationship with a male (p < .001, d = .32) or female partner living with HIV (p < .001, d = .31). Perceived HIV risk did not significantly differ by whether the patient currently had a male or female partner living with HIV (p = .93). Additionally, the patient who only had female partners in the past was perceived as being at lower risk for HIV compared to the patient who only had male partners in the past (p < .001, d = .23) and the patient who had both male and female partners in the past (p = .001, d = .18). Perceived HIV risk did not differ by whether the patient had only male versus both male and female partners in the past (p = .31).

There was also a significant interaction between current and past partner gender on perceived HIV risk (Wald Chi-square = 14.85, p = .005). When the participant was not described as being in a current relationship, participants rated the patient who only had female partners in the past as being at lower risk for HIV compared to the patient who only had male partners in the past (p < .001, d = .58) and the patient who had both male and female partners in the past (p < .001, d = .34). Participants also rated the patient who had both male and female partners in the past as being at lower risk for HIV compared to the patient who only had male partners in the past (p = .04, d = .25). In contrast, when the participant was in a current relationship with a male or female partner living with HIV, there were no significant differences in perceived HIV risk based on past partner gender (ps > .23).

Perceived likelihood of adherence to PrEP.

The main effect of current partner gender (Wald Chi-Square = 8.52, p = .01) on perceived likelihood of adherence to PrEP was significant. Pairwise comparisons indicated that the patient who was not described as being in a current relationship was rated as less likely to adhere to PrEP compared to the patient who currently had a male partner living with HIV (p = .01, d = .15) or a female partner living with HIV (p = .02, d = .12). Perceived likelihood of adherence to PrEP did not differ by whether the patient currently had a male or female partner living with HIV (p = .64). The main effect of past partner gender (p = .052) and the interaction between current partner gender and past partner gender (p = .18) were not significant.

Perceived likelihood of engaging in condomless sex if prescribed PrEP.

The main effect of current partner gender on perceived likelihood of engaging in condomless sex if prescribed PrEP was significant (Wald Chi-Square = 8.60, p = .01). Pairwise comparisons indicated that the patient who was not described as being in a current relationship was rated as less likely to engage in condomless sex if prescribed PrEP compared to the patient who currently had a male partner living with HIV (p = .01, d = 0.15) or a female partner living with HIV (p = .03, d = .12). Perceived likelihood of engaging in condomless sex did not differ by whether the patient currently had a male or female partner living with HIV (p = .54). The main effect of past partner gender and the interaction between current and past partner gender on perceived likelihood of condomless sex if prescribed PrEP were not significant (ps > .52).

Post-hoc indirect effect analyses

In our primary analyses, we found significant main effects of past partner gender on perceived HIV risk and likelihood of prescribing PrEP (they were both lower for the patient who only had female partners in the past compared to the patient who only had male partners and the patient who had both male and female partners in the past). We also found significant interaction effects between past and current partner gender on perceived HIV risk and likelihood of prescribing PrEP (the effects of past partner gender were only significant when the patient was not described as being in a current relationship). Given these findings, and that perceived HIV risk was positively associated with likelihood of prescribing PrEP, we tested the possibility that perceived HIV risk could potentially explain the effects of past partner gender on likelihood of prescribing PrEP for patients who were not in a current relationship. Specifically, we examined whether there was an indirect effect of past partner gender on likelihood of prescribing PrEP via perceived HIV risk using data from only conditions in which the patient was not in a current relationship. Similar to our primary analyses, these analyses also controlled for participant age, gender, sexual orientation, race, program type, and program year.

The indirect effect analyses demonstrated that having only male partners in the past (b = .72, SE = .15; p < .001) and having both male and female partners in the past (b = .40, SE = .16; p = .01) were significantly associated with greater perceived HIV risk relative to having only female partners in the past. In turn, greater perceived HIV risk was significantly associated with greater likelihood of prescribing PrEP (b = .70, SE = .08, p < .001). The indirect effects of having only male partners in the past (b = .50; SE = .13; 95% CI: .27, .77) and having both male and female partners in the past (b = .28; SE = .12; 95% CI: .05, .55) on likelihood of prescribing PrEP via perceived HIV risk were significant. The model accounted for 36.7% of the variance in likelihood of prescribing PrEP.

Discussion

The goals of the current study were to examine whether medical students’ perceptions of a bisexual male patient (whether they were a candidate for PrEP, their willingness to prescribe PrEP to the patient, the patient’s HIV risk, and their assumptions about the patient’s behavior if prescribed PrEP) were influenced by the genders of his current and past partners. Several key findings emerged.

First, we found significant interactions between current and past partner gender on perceived HIV risk and likelihood of prescribing PrEP. When the patient was not in a current relationship, participants perceived him as being at the lowest risk for HIV if he only had female partners in the past, followed by if he had both male and female partners in the past, and then if he had only male partners in the past. This may reflect medical students’ knowledge of epidemiological trends in which MSM are at greater risk for HIV than are men who have sex with women exclusively (Friedman, Wei, et al., 2014). However, all of the patients in the current study who were not in a current relationship were described as having engaged in intermittent condom use with partners of unknown HIV-status. According to the most recent guidelines for PrEP prescription, all sexually active adults and adolescents should receive information about PrEP. Specifically, sexual activity with a partner living with HIV and a history of inconsistent or no condom use are two indications for PrEP, regardless of gender (CDC, 2021a). Further, in the most recently updated December 2021 CDC guidelines, the CDC indicates that a patient request for PrEP is sufficient justification for prescription (CDC, 2021a). Based on the current findings, medical students may require additional education related to PrEP to ensure that they understand the criteria for eligibility and that they make decisions based on each patient’s individual presentation and risk factors rather than relying on epidemiological trends.

Second, the same pattern was observed for likelihood of prescribing PrEP. When the patient was not in a current relationship, participants were least likely to prescribe PrEP if the patient had only female partners in the past, followed by if he had both male and female partners in the past, and then if he only had male partners in the past. The results of post-hoc analyses supported the hypothesis that past partner gender influenced likelihood of prescribing PrEP via its influence on perceived HIV risk. In other words, because the patient who had only female partners in the past was perceived as being at lowest HIV risk, medical students were least likely to prescribe him PrEP. Again, this may make sense from a strictly epidemiological perspective, but the patient was described as having a history of engaging in intermittent condom use with multiple partners of unknown HIV-status, and it is still possible to acquire HIV from a female partner, as evidenced by the approximately 3,000 annual HIV diagnoses among men in the U.S. attributed to heterosexual contact (CDC, 2021b).

In contrast, when the participant was in a current relationship with a partner living with HIV, perceived HIV risk and likelihood of prescribing PrEP did not differ based on the genders of his current and past partners. This is encouraging as it suggests participants were appropriately attending to the most important information relevant to whether or not to prescribe PrEP (i.e., that the patient’s partner was living with HIV) rather than the genders of his current and past partners. However, this requires providers to inquire about the HIV-statuses of their patients’ partners and for patients to disclose their partners’ HIV-statuses. Unfortunately, barriers may prevent these from happening, such as providers not taking comprehensive sexual histories (Brookmeyer et al., 2021), and HIV-related stigma limiting disclosure of being in a serodifferent relationship.

Finally, we found significant main effects of current partner gender on perceived PrEP candidacy, perceived likelihood of adherence to PrEP, and perceived likelihood of having condomless sex if prescribed PrEP. When the patient was not in a current relationship, participants were less likely to identify him as a PrEP candidate compared to when the patient currently had a male or female partner living with HIV. These findings are consistent with evidence that physicians are more likely to prescribe PrEP to HIV-serodifferent couples than to single MSM (Adams & Balderson, 2016; Smith et al., 2016). However, the majority of participants in our study indicated that the patient was an appropriate candidate for PrEP regardless of whether or not they were in a relationship with a partner living with HIV. Similarly, when the patient was not in a current relationship, they were rated as less likely to adhere to PrEP and less likely to have condomless sex if prescribed PrEP compared to when the patient was in a current relationship with a male or female partner living with HIV. These findings may reflect medical students’ assumptions that when a patient is in a relationship with a partner living with HIV, they would be more adherent to PrEP to prevent themselves from acquiring HIV and they are going to be more likely to engage in condomless sex because they are in a monogamous relationship.

Limitations

The current findings should be considered in the context of several limitations. First, all of our participants were medical students in the U.S. and it is unknown whether our findings would generalize to medical students outside the U.S. It will be important for future research to examine potential biases in willingness to prescribe PrEP to bisexual men among medical students outside the U.S. Second, consistent with previous research (Calabrese et al., 2014, 2018), when the patient was described as being in a current relationship, the partner was described as living with HIV and the relationship was described as monogamous. We chose to describe the partner in this way because we wanted there to be some degree of HIV risk and we did not think it would be believable to say that the patient did not know the HIV-status of his partner. By doing this, we were able to demonstrate that the effect of past partner gender was mitigated by the HIV-status of the current partner. This suggests that, when the patient was described as being in a current relationship, the participants were appropriately attending to the most important information relevant to whether or not to prescribe PrEP (i.e., that the patient’s partner was living with HIV). In contrast, when the patient was not in a current relationship, participants’ assumptions and decisions were biased based on the genders of the patient’s past partners. Given that the relationship was described as monogamous, it will be important for future research to examine whether willingness to prescribe PrEP to bisexual men in non-monogamous relationships depends on the genders of their partners.

Third, the vignette explicitly stated that the patient was bisexual, and it is likely that some bisexual patients will not be comfortable disclosing their sexual identity or behaviors to providers. Fourth, although our vignettes were formatted as simulated EMRs, they did not include information about the patient’s race or ethnicity. Previous research has found that racial bias can also influence medical students’ and physicians’ decisions related to PrEP prescription (Calabrese et al., 2014), and the stereotype of Black bisexual men as being “on the down low” (i.e., identifying as heterosexual but secretly engaging in sex with both men and women) (Dodge et al., 2008) suggests that perceptions of Black bisexual men may be different than perceptions of bisexual men of other races. Fifth, across conditions, the patient’s partners were described as men and/or women, but we did not specify whether they were cisgender or transgender and we did not include nonbinary partners. Given that transgender women are also disproportionately affected by HIV (Baral et al., 2013), there are likely differences in perceptions of HIV risk and willingness to prescribe PrEP to a bisexual male patient who has only had female partners depending on whether they have been cisgender or transgender.

Sixth, we did not present participants with a description of PrEP prior to presenting them with the clinical scenarios. That said, we did administer a brief assessment of PrEP knowledge after the clinical scenarios, and the results indicated that most participants had a fair amount of knowledge about PrEP. Further, when we included PrEP knowledge as a covariate in our analyses, the pattern of significant findings remained the same. Future studies may benefit from providing participants with information about PrEP prior to presenting them with clinical vignettes. Seventh, the demographic characteristics of our participants were somewhat different from the larger population of medical students in the U.S. in 2020–2021 (American Association of Colleges of Osteopathic Medicine, 2022; Association of American Medical Colleges, 2022). For example, the proportion of cisgender women in our sample (62.3%) was greater than the proportion of female medical students in allopathic (51.5%) and osteopathic (49.4%) medicine programs in the U.S. The proportion of White students in our sample (53.9%) was similar to the proportion of White students in osteopathic medicine programs in the U.S. (56.9%), but it was slightly higher than the proportion of White students in allopathic medicine programs in the U.S. (47.6%). It is likely that our sample was also over-representative of sexual and gender minority students, but the available national data do not include these demographic characteristics.

Eight, we removed 90 responses with missing data (e.g., participants who stopped halfway through the study). Given that we administered the demographic questions at the end of the study, we were unable to examine whether demographic characteristics differed between participants who completed the study and those who did not. Finally, although it is important to understand medical students’ decision-making related to PrEP prescription, the current findings may not generalize to prescribers (e.g., physicians). It will be important for future studies to replicate the current study among physicians and other prescribers.

Conclusions

Limitations aside, the current study has important implications for our understanding of medical students’ (and thus future clinicians’) decision-making with respect to PrEP prescription. While it is encouraging that participants were appropriately attending to the most important information when the patient was in a relationship with a partner living with HIV, it is discouraging that participants’ assumptions and decisions were influenced by the genders of the patient’s past partners when the patient was not in a current relationship. Given evidence of knowledge gaps related to PrEP prescription and management among physicians (Furukawa et al., 2020; Smith et al., 2016; Wood et al., 2018) and medical students (Bunting, Garber, Goldstein, Calabrese, et al., 2020; Bunting, Feinstein, Hazra, Sheth, et al., 2021; Przybyla et al., 2021), the current findings suggest that medical students may require additional education related to PrEP to ensure that they understand the criteria for eligibility and that they make decisions based on each patient’s individual presentation rather than relying on epidemiological trends.

Further, given that bisexual men with female partners are less likely to disclose their sexual orientation than those with male partners (Feinstein et al., in press), it is critical for providers to create an affirming environment that maximizes the likelihood of patients feeling comfortable disclosing their sexual orientation and behavior. Previous research has found that providers do not regularly take sexual histories and, when they do, they are often not comprehensive (Brookmeyer et al., 2021). Consistent with the CDC’s recommended approach to taking a sexual history, providers should be asking patients about their sexual partners, sexual practices, use of protection, past history of sexually transmitted infections, and pregnancy intentions (CDC, 2021c). In doing so, providers should not assume patients’ sexual behavior based on their self-reported sexual orientation. Instead, they should be sure to ask all patients about sexual behavior with partners of different genders, including their knowledge of their partners’ HIV-status and whether they consistently use protection with each partner. By conducting comprehensive sexual histories, providers can make more informed recommendations regarding the potential use of PrEP. In sum, the current findings suggest that medical students’ perceptions of bisexual male patients may be influenced by whether their past partners have been all men, all women, or both. As such, medical students may require additional education related to PrEP to ensure that they understand the criteria for eligibility and that they make decisions based on each patient’s individual presentation rather than relying on epidemiological trends.

Funding:

This project was supported by a grant from Gilead Sciences under award number IN-US-412–9042 (PI: Garber, Co-I: Bunting). The funder had no input on study design, implementation, data analysis, interpretation of results, drafting of the report, or the decision of where to submit the report for publication. Brian Feinstein’s time was supported by a grant from the National Institute on Drug Abuse (K08DA045575). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.

Footnotes

Conflicts of interest: The authors do not have any conflicts of interest to disclose.

Code availability (software application or custom code): Syntax for statistical analyses are available from the lead author upon request.

Research involving Human Participants and/or Animals: All study procedures were approved by the Institutional Review Board at Rosalind Franklin University of Medicine and Science prior to implementation. The study was performed in accordance with the ethical standards in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent: Online informed consent to participate was obtained from all participants.

1

We re-ran our analyses including PrEP knowledge as a covariate and the pattern of significant findings remained the same.

Availability of data and material (data transparency):

Data are available from the lead author upon request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data are available from the lead author upon request.

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