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First publication from my PhD research, co-authored with @martinxholt, Bridget Haire & @thisnewman exploring clinician views on providing PrEP for HIV anxiety - message me if you cannot access.
@CSRH_UNSW @KirbyInstitute
https://journals.lww.com/janac/Abstract/9000/Issues_Associated_With_Prescribing_HIV.99836.aspx
A thread on the article
@CSRH_UNSW @KirbyInstitute
https://journals.lww.com/janac/Abstract/9000/Issues_Associated_With_Prescribing_HIV.99836.aspx
A thread on the article
HIV anxiety (sometimes called 'sexual anxiety') is not a clinical condition, but implies significant concern about being at risk of, testing for, and/or being diagnosed with HIV. @PkeenKeen & co show reduced HIV anxiety for Aus GBM using PrEP.
2/22 https://doi.org/10.1097/QAI.0000000000002232
2/22 https://doi.org/10.1097/QAI.0000000000002232
e.g. in @shanah29 and co, 'Brad' re: using PrEP:
âI had never known that level of non-anxiety. You always go to bed with anxiety, right? You want to be with somebody, itâs like, itâs the third partner whoâs always there. [laugh] Thatâs the anxiety.â
3/22 https://www.tandfonline.com/doi/full/10.1080/01459740.2017.1416608
âI had never known that level of non-anxiety. You always go to bed with anxiety, right? You want to be with somebody, itâs like, itâs the third partner whoâs always there. [laugh] Thatâs the anxiety.â
3/22 https://www.tandfonline.com/doi/full/10.1080/01459740.2017.1416608
U=U (Undetectable equals untransmittable) has also transformed sex for people living with HIV and their partners - see https://www.preventionaccess.org/ - re: international scientific consensus that a person on treatment w/ undetectable viral load CANNOT transmit HIV sexually.
4/22
4/22
Aus @ASHMMedia guidelines do not indicate PrEP prescription if only sexual partner has undetectable viral load.
But guidelines do support prescribing for those experiencing HIV anxiety, including in serodiscordant (mixed HIV status) relationships.
5/22
https://ashm.org.au/resources/hiv-resources-list/prep-guidelines-2019/
But guidelines do support prescribing for those experiencing HIV anxiety, including in serodiscordant (mixed HIV status) relationships.
5/22
https://ashm.org.au/resources/hiv-resources-list/prep-guidelines-2019/
So what do clinicians providing PrEP think about HIV anxiety? Provider studies have mentioned management of HIV anxiety as part of providing PrEP - clinicians oft uncomfortable prescribing to those with low HIV risk. But rarely explored in-depth.
6/22
http://www.liebertpub.com/doi/10.1089/apc.2017.0031
6/22
http://www.liebertpub.com/doi/10.1089/apc.2017.0031
As part of wider project exploring clinician views on providing PrEP (given scarce Aus literature - Smith & co). We interviewed 25 sexual health nurses, SH physicians, and general practitioners who provide PrEP in NSW and WA between 2019-2020.
7/22 https://www.tandfonline.com/doi/full/10.1080/14461242.2019.1703781
7/22 https://www.tandfonline.com/doi/full/10.1080/14461242.2019.1703781
This article explores an analysis of 3 themes:
(1) Transforming gay menâs HIV anxiety through PrEP
Clinicians told us how valuable PrEP was in transforming HIV anxiety for gay men, creating "a very different world in sexual health" [P01 SH Nurse]
8/22
(1) Transforming gay menâs HIV anxiety through PrEP
Clinicians told us how valuable PrEP was in transforming HIV anxiety for gay men, creating "a very different world in sexual health" [P01 SH Nurse]
8/22
For older gay men, clinicians explained that PrEP provided relief from decades of trauma and distress from HIV (Odets)
But also clinicians saw HIV anxiety in younger gay men, and PrEP made them feel more comfortable about being gay.
9/22
https://www.dukeupress.edu/In-the-Shadow-of-the-Epidemic
But also clinicians saw HIV anxiety in younger gay men, and PrEP made them feel more comfortable about being gay.
9/22
https://www.dukeupress.edu/In-the-Shadow-of-the-Epidemic
(2) PrEP as âpeace of mindâ for serodiscordant couples.
Clinicians iterated U=U, and explained that PrEP was clinically unnecessary unless risk from outside couple. But they also viewed PrEP as beneficial to managing HIV anxiety, including from the HIV positive partner.
10/22
Clinicians iterated U=U, and explained that PrEP was clinically unnecessary unless risk from outside couple. But they also viewed PrEP as beneficial to managing HIV anxiety, including from the HIV positive partner.
10/22
Some speculated about reliability of viral loads, suggesting PrEP might be necessary despite U=U.
A few were worried that providing PrEP 'suggested' to the patient that U doesn't equal U, hinting that it was necessary to prevent intra-couple transmission in context of U=U
11/22
A few were worried that providing PrEP 'suggested' to the patient that U doesn't equal U, hinting that it was necessary to prevent intra-couple transmission in context of U=U
11/22
Others emphasised individual prevention, comparing to oral contraception and notion of shared responsibility in managing preventing (not relying solely on U=U), but also ensuring power is equal in relationships.
Educating about U=U as part of prescribing PrEP important!
12/22
Educating about U=U as part of prescribing PrEP important!
12/22
(3) Configuring the âworried well": No risk or undisclosed behaviour?
'Worried well' is a poorly defined and problematic term - it privileges physical distress over mental distress and undervalues exp. of anxiety (Gray & co).
13/22 http://bjgp.org/lookup/doi/10.3399/bjgp20X708017
'Worried well' is a poorly defined and problematic term - it privileges physical distress over mental distress and undervalues exp. of anxiety (Gray & co).
13/22 http://bjgp.org/lookup/doi/10.3399/bjgp20X708017
Clinicians found those who reported no/little risk ('worried well') and requesting PrEP frustrating - a waste of clinical resources - and yet this is exactly the type of person who is allowed to be prescribed PrEP under the 'anxiety' provision.
14/22
14/22
Clinicians instead felt comfortable with providing PrEP to 'worried well' by imagining they had undisclosed risk - suggesting it clinically necessary to prescribe for this undisclosed risk - so instead of prescribing for anxiety they were prescribing for undisclosed risk.
15/22
15/22
These findings suggest that providing PrEP for HIV anxiety is valued by Aus PrEP providers, but HIV anxiety is situated - some types of anxiety (for gay men and for serodiscordant couples) are valued more than for others ('worried well').
16/22
16/22
@ejnicholls_ & Rosengarten argued that PrEP changes the possibilities for clinician interactions with patients. But our findings suggest this is constrained by reliance on 'risk' framing, despite potential for PrEP to have effects beyond prevention
17/22 https://journals.sagepub.com/doi/10.1177/1363460719886556
17/22 https://journals.sagepub.com/doi/10.1177/1363460719886556
Devarajan & co found that MSM in U.S. disliked focus in PrEP consultations on risk, and would prefer clinicians to focus on positive benefits of PrEP on sexual health
18/22 https://www.tandfonline.com/doi/full/10.1080/09540121.2019.1695734
18/22 https://www.tandfonline.com/doi/full/10.1080/09540121.2019.1695734
It is promising that Aus clinicians (experienced sample) were enthusiastic about U=U, but suggests that there were some aspects they were unsure of - e.g. reliability of viral loads - and speaks to more complicated dynamics of trust in science and in relationship contexts
19/22
19/22
Our concluding remarks:
"PrEP providers [...] ought to provide PrEP in ways that extend beyond preventing HIV, enabling flourishing sexual lives for people [...] recognising pleasure and wellbeing, rather than simply the prevention or treatment of disease."
20/22
"PrEP providers [...] ought to provide PrEP in ways that extend beyond preventing HIV, enabling flourishing sexual lives for people [...] recognising pleasure and wellbeing, rather than simply the prevention or treatment of disease."
20/22
And our recommendations
21/22
21/22
Thanks to our study advisory panel (see acknowledgements) and the clinicians who took part in our study. 
And thanks to @CSRH_UNSW, my supervisors (co-authors) and to @UNSWArts for funding interview compensation & transcribing
22/22
And thanks to @CSRH_UNSW, my supervisors (co-authors) and to @UNSWArts for funding interview compensation & transcribing
22/22
