July 21, 2021 • 45 mins
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/
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Episode Transcript
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Valerie Earnshaw (00:11):
I'm Valerie Earnshaw.
Carly Hill (00:13):
I'm Carly Hill.
Valerie Earnshaw (00:14):
and this is Sex Drugs and Science.
Carly Hill (00:17):
Today's conversation is with Sarah Calabrese, who is
an assistant Professor ofPsychology at George Washington
University.
Her research focuses on sexualhealth promotion among racial
and sexual minorities and othersocially marginalized groups.
Valerie Earnshaw (00:32):
A key part of Sarah's work aims to identify
and address barriers to HIVprevention, including
pre-exposure prophylaxis orPrEP.
So PrEP is a daily pill that canbe taken to prevent HIV.
It's actually a really importantmedication.
It's super promising in reducingthe spread of HIV.
But interestingly enough, not alot of people are taking it.
(00:54):
So we try to understand why morepeople aren't taking PrEP when
we taught it with Sarah.
Carly Hill (01:00):
And you guys will notice for this episode that I
am missing.
I got into a little fenderbender on the way to record the
podcast, but I, you know, knewthat Valerie could somehow
handle the show without me.
So I think you'll find she did agreat job.
Valerie Earnshaw (01:16):
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 complaintsthat way, but anyway, Carly, we
super miss you, super glad thateverything's okay.
And we hope that everyone outthere enjoys this conversation
(01:39):
with Sarah Calabrese.
All right.
Dr.
Calabrese is thanks for joiningus on the podcast.
Dr. Sarah Calabrese (01:51):
I'm happy to be here.
Thanks for having me.
Valerie Earnshaw (01:53):
So, Sarah, you received your PhD in clinical
psych from George Washingtonuniversity.
And I realized that althoughwe've known each other for
almost a decade now, and also, Ifeel like I could order for you
at sushi.
We,'ve had our sushi dates, thatI actually don't know, like the
(02:16):
backstory in terms of why youdecided to pursue clinical psych
specifically.
Dr. Sarah Calabrese (02:22):
Yeah.
So in college I was a doublemajor in biology and psychology
and the original plan was to gointo medicine.
I became very interested inpsychological science and kind
of how psychological processesrelated to health.
And so for that reason, clinicalpsych seems like a good fit.
And the idea of a clinical psychPhD was desirable because I
(02:45):
would get training in bothresearch as well as clinical
work, if I wanted to go downthat path, which I wasn't sure
about at the time.
So also I think that medicinewould have been a terrible thing
for me in retrospect, becauseI'm super squeamish.
And so I think this is reallythe best way to go.
Valerie Earnshaw (03:03):
That's awesome.
That's really interesting thatyou were interested in medicine.
I didn't know that.
And that makes sense.
I mean, we'll talk about thismore, but you've developed this
big interest in this likebiomedical technology, this
like, PrEP, which is an HIVprevention pill, so, or HIV
prevention medication, eventhough you didn't pursue the MD,
(03:25):
you're still like very muchworking in that area.
So,
Dr. Sarah Calabrese (03:28):
And also studying MDs.
Right?
A lot of my work is aroundhealthcare providers and
provider bias.
So yeah, I guess I didn'ttotally get away from medicine.
Valerie Earnshaw (03:41):
So when you were in your grad program, it
sounds like your particular gradprogram was like a really
terrific fit for you because youwere in the clinical psych
program at George Washington.
And there are a bunch of folkswho have this interest in
science and medicine.
And I saw that you worked on astudy of HIV medication
(04:01):
adherence and disclosure whileyou were a grad student.
So is that where your like,interest in HIV started to
percolate?
Dr. Sarah Calabrese (04:07):
So I think my interest in HIV really
started back in college, likegoing into grad school, you
know, you apply to work with aparticular mentor.
And so I applied to work withDr.
Maria Cecilia Zea because of thework that she was doing around
understanding HIV risk andprevention with Latino MSM.
So the interest in HIV startedprior to that, and it was just,
(04:30):
it's always been something thatI've gravitated towards.
I think a lot of people havethese 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 partof that is recognition that it
disproportionately affectscommunities that are already
(04:53):
disadvantaged, recognizing thatthat was a social problem.
And then I think also there wasintellectual curiosity because
on the one hand we hadprevention tools that we knew
worked.
And so in theory, HIV could beprevented and yet, clearly it
wasn't being prevented.
The spread was still happening.
(05:14):
And so I wanted to understandwhat the barriers were to the
use of existing tools.
So I think that's kind of wheremy interest in HIV came from.
And then when I went to gradschool, I went specifically to
work with Maria Cecilia andthen, yeah, I mean, as he spoke
to, it was a good fit in termsof the work people were doing
there.
And other people were interestedin work that was really more
(05:37):
community focused and appliedhealth.
And so all of those thingsappeal to me.
Valerie Earnshaw (05:42):
It's really interesting hearing you talk
about it because I think I waslike attracted to studying HIV
in grad school for similarreasons.
You know, I think I developed myinterest in stigma earlier, but
then HIV is just such like aperfect playing field to study
stigma, all of these socialdynamics or health disparities.
(06:04):
I mean, HIV is terrible.
That it's the case, but becausethere are so many disparities
because of some of these issuesthat you're highlighting around,
you know, we know what stops HIVtransmission, why is it
happening?
You know, it's reallyinteresting place to work, I
think, as the scientists, butmaybe even, especially like as a
social scientist.
Dr. Sarah Calabrese (06:22):
Yeah, yeah.
Like really understanding someof those social factors and
social processes that arecontributing to the spread.
Valerie Earnshaw (06:29):
Yeah.
Yeah.
All right.
Well then both of our pathsconverge, when we were post-
docs.
So we both did the post-doctoralfellowship at the center for
interdisciplinary research onaids at Yale university.
And as I was thinking throughyour timeline, I was like, oh
wow, because you were a post-docat this really fantastic place
(06:53):
to, you know, study HIV and digin to HIV research.
Although you had started thatearlier, but at the same time
that PrEP is approved by theFDA.
So is that then where theinterest in PrEP starts to
emerge or where had you beeninterested in it beforehand?
Because the trials for it hadbeen going on for some years
(07:13):
before FDA gave the green lightfor folks to use it.
Dr. Sarah Calabrese (07:17):
Yeah.
I mean, I think that my interestreally took off sort of, end of
grad school, beginning of postdoc.
You know, it really coincidedwith the release of the results
from iPrEx and the, which is aclinical efficacy study, as well
as other clinical studies andthen FDA approval in 2012.
(07:37):
That was all around the timethat I was doing my postdoc.
And I think in grad school PrEPwas on the radar and particular
microbicides, but it was reallyat the time I wasn't doing work
related to that.
It was really kind of once thetrial results were released that
looked so promising once FDAapproval occurred and PrEP just
(07:59):
seemed fantastic.
PrEP is fantastic, but you know,it really just seemed like this
game changer or like all of asudden we've been struggling to
curb the spread of HIV becauseof X, Y, and Z reasons.
And like, we keep trying to pushthese other prevention methods,
but clearly it's not enough.
And then like suddenly PrEPcomes on the scene and it
(08:19):
circumvents so many of thechallenges associated with other
prevention options.
And so how could you not getexcited about that?
I think that, you know, myresearch is just kind of moving
with the science and it was ingrad school, as you know, that I
did that, we did that initialstudy where we looked at medical
students and their clinicaljudgment and clinical
(08:44):
decision-making related to PrEPand how it may differ according
to the race of the patient andgetting those initial results
that suggested that biases couldcome into play when it came
prescribing PrEP.
And that could have implicationsfor access.
I think that really just laidthe foundation for my subsequent
research trajectory.
Valerie Earnshaw (09:06):
Arc is lit.
I remember going to a conferencewith you in New York city.
I don't remember much about theconference, but I do remember
sitting at these like longtables with you.
And you were thinking about thatstudy and you were talking it
through out loud and sometimes,you know, you talk to people
about their research ideas andyou're like, I don't know if you
(09:29):
are really into this part, youknow, but you were like, you
were all lit up about it.
You like follow that this, thatyou were like really excited
about it.
And oftentimes, you know, you,you leave the conference, you
leave the room and you don't dothe study, but you did the
study, and then some, which islike really amazing.
So I'll have to come back to themethods of that.
Dr. Sarah Calabrese (09:47):
I was thinking about that conference
as well.
I think that's really where theidea initially you took off.
And I remember you being therereally encouraging me.
And I think that you wereinstrumental in me actually
carrying out the study becauseyou 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 beexcited and encouraging of like
a really excellent idea.
So I'll just wrap up the careertrajectory part and then I'll
push us to talk more about likewhat PrEP actually is, because
I'm sure some folks arewondering.
But I just want to mention thatafter postdoc and a few
additional years at Yale, thatyou returned to GW, George
(10:29):
Washington University as afaculty member in 2016.
And I just want to put out therethat that's quite remarkable
because many graduate students,when they're doing their
training, there, they're verymuch warned that it is difficult
to be hired by the departmentthat trained you.
You'll never say this, but it'squite a big deal.
And it really speaks to thequality of your work, I think,
(10:52):
that your department wanted youback 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 justreally 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 thatwas knowing the department and
knowing the program is why itwas such a big draw for me as
well.
Like just having thatfamiliarity, knowing who my
colleagues would be, knowing thekind of work people were doing,
the environment, the setting,DC, all of it.
It's just, I enjoyed it in gradschool.
(11:29):
And I was really excited to havethe opportunity to come back.
Valerie Earnshaw (11:32):
Yeah.
It's a really phenomenaldepartment for people,
especially like you who havethis interest in inequity,
social factors, crossovers withlike medicine and, and health.
It's like, it's a, it's a prettyunique psychology department in
that way.
Dr. Sarah Calabrese (11:49):
It really is.
I don't know how many psychologydepartments my stuff would
really fit in.
And GW just struck me as sounique because as I said, there
really is an intersection ofpsychology and public health.
And particularly is related, alot of people do work related to
HIV in our department, but alsoat GW there is a NIH funded
(12:10):
center that's based in GW andencompasses many institutions in
DC.
So like, it's really a idealplace to be doing HIV research.
Valerie Earnshaw (12:20):
Yeah.
Okay.
So now we've been talking aboutit for like 15 minutes.
So maybe we could talk aboutwhat PrEP is for folks who may
not be familiar with it.
Maybe think about who iseligible for PrEP.
Cause not everyone is prescribedPrEP, although maybe they should
be, but
Dr. Sarah Calabrese (12:38):
Yes.
So PrEP is Pre-exposureProphylaxis and it is medication
that is taken on an ongoingbasis by somebody who is HIV
negative in order to prevent theacquisition of HIV.
It's incredibly effective, atleast 99%, which, I mean, that's
just unreal.
That's- people hesitate or youknow object, to calling it a
(13:02):
silver bullet, but I don'tunderstand why we don't, it
feels like it is! Currently theform of PrEP that is FDA
approved is a once a day pill.
There's a couple of differentformulations, but there are
other dosing and deliverystrategies that are kind of in
the pipeline, event-drivendosing, where you're not taking
medication every day, but you'retaking it around the time of a
(13:25):
potential transmission event.
There's also different deliverystrategies that are in a lot of
ways sort of like birth control.
So there's injections, there'simplants, there's rings, et
cetera.
So, you know, these are variousstages of testing and
development, but I think thatit's very promising in terms of
what might be available down theline.
(13:46):
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 allthe, like all the various ways
that it could come out, downthe, down the line, especially
like as women or as I'll just doto myself, like as a woman,
having so many options for birthcontrol is really helpful, you
know, and different things workbest for different people.
So the idea that there's goingto 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 abouteligibility.
So this is maybe a controversialissue.
I mean, it's something that isapproved for US adults who are
at risk because of their sexualbehavior or because of their
injection drug practices, forexample, sharing needles.
(14:34):
Those are the people who couldbenefit from it.
And it's also available, Ishould say, not just adults, but
adolescents as well.
There are various sort ofcriteria and guidelines that
have been put out there, which Igenerally 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, plushave had anal or vaginal sex in
the past six months, plus have asexual partner with HIV, or is
someone who doesn't consistentlyuse condoms, or someone who has
been diagnosed with an STD inthe past six months." So that's,
(15:12):
that's like the sexualtransmission route.
And then for people who injectdrugs, it's"if you have an
injection partner, so you'resharing needles with someone who
has HIV or if you kind ofgenerally share injection
equipment.
So maybe you're sharing, youknow, needles or injection
equipment with someone who hasHIV." So, okay.
So those criteria for who iseligible to PrEP sound rather
(15:34):
conservative to you.
So please, please tell me whythey sound conservative.
Dr. Sarah Calabrese (15:38):
Yeah.
So I think my concerns, there'stwo ways of thinking about it.
So one is how the criteria areused 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 ofclinicians use them as
guidelines, to determine who totalk about PrEP with.
And so, you know, to the extentthey are unaware of patient's
(16:02):
behavior, or patients' needs, orpatients behavioral goals, like
they may or may not be talkingto a given patient, even though
the patient could potentiallybenefit.
In terms of what is actually inthe criteria.
We know that past behavior doesnot necessarily predict future
behavior.
And so the fact that somebodyhas had condom-less sex with a
(16:25):
partner of unknown statusmultiple times in the last six
months doesn't mean anythingabout the next six months or
their plans for the next sixmonths.
So I think using past behavioras an indicator can be
problematic.
I think it also warrantsconsideration, the fact that
this is really private,sensitive information about a
patient that you are potentiallyasking about or thinking about.
(16:49):
And so patients may or may notprovide that information to
their providers.
Understandably so, and they maynot be motivated to share
intimate details of their sexlife when they don't realize
that being informed about PrEPis contingent on their doing so,
like they may not reallyperceive a benefit in sharing
that information with theirprovider.
(17:10):
And so I think that having theprovider be the decision maker
about who gets to hear aboutPrEP, that is a problem.
And I think that the criteriathemselves, there are somewhat
complicated.
They depend on individual levelbehavior.
It's been shown that this canactually lead to disparities in
(17:30):
terms of who's eligible.
So for example, black Americanshave been less likely to be
deemed eligible than whiteAmericans in some studies.
And that may be because theirrisk factors being less about
individual level behavior andmore about sort of networks or
communities.
I think the criteria that hadbeen used are in need of reform,
(17:53):
but I will also say the CDC isreforming 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 guidelinesthat are posted online and there
are webinars where they areinviting public comment next
week, who knows what the nextedition or iteration might be.
But I did note in the draft thatthey were suggesting, talking
about PrEP with all sexuallyactive adults.
So that's a step in the rightdirection.
(18:22):
I'd still like to see somechanges with that, but it's
better than what we havealready.
So perhaps they're evolving.
Valerie Earnshaw (18:29):
Yeah.
So one of the things we're kindof digging into a little bit
this season, Sarah is around theintersection of like of
scientists and policies.
So, I mean, you were able totell me exactly like when these
meetings are so as a scientist,like, do you plan to get
feedback?
Do you plan to participate inthese?
Like, are you trying to shareyour expertise, with the CDC as
(18:51):
they are- in a perfect world,they would come to you.
Right.
But, they don't usually come tous.
So are you trying to like speakup 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 whatI'm going to say.
And I think it's important toattend these kinds of things.
If you want to have an impactthey're not accepting public
comment otherwise, so that wouldbe the place to do it.
When the US preventative taskforce was developing their PrEP
guidelines.
I wrote a letter and outlinedthe reasons, that I thought that
(19:26):
these criteria should be X, Y,and Z or changed.
And I have made some smallefforts in that respect, but I
don't think that I've beenconsistent about contacting
specific branch of the CDC withmy ideas.
You know, I publish on them, butI could probably do more.
Valerie Earnshaw (19:41):
No, but I mean, I think it's great even
that you are writing lettersthat when the opportunity, when
the CDC says,"Hey, we'relistening", you're like,"All
right, buckle up.
I'm coming." I think that whenthere are opportunities, like
what are you going to do driveto 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'snot going to count towards your
promotion and tenure to talkabout your advocacy work with
the CDC.
So anyway, I think that'sawesome.
I think it's great that youthink about, you know, speaking
up.
Okay.
So to take us back to some ofthese issues around why it's
important to revise some ofthese guidelines, it seems like
(20:24):
a lot of people who couldbenefit from PrEP, aren't
actually receiving it.
So some data that you sharedwith me before this recording
was that there are estimated tobe at least 1.8 million people
in the US who would be eligiblefor PrEP, but only 18.1% of them
have been prescribed it.
So I, I continue to think thatthat's bananas.
(20:48):
I mean, that's a pretty smalllike group of people who could
benefit by this.
And we're talking aboutbenefiting from it, from these
like conservative eligibilitycriteria.
Right.
So if we, if we've thoughtthrough that even more, there's
probably like a lot more peoplewho could benefit from, so the
percentage of people getting it,who could, who could be helped
(21:08):
from it is quite small,
Dr. Sarah Calabrese (21:11):
Right?
Yeah.
So it's probably the case thatthe percentage is much smaller
than 18%.
If you're taking intoconsideration the full gamut of
people who could benefit fromit.
And I think that part of thereason for that is that it's not
being made available to otherpeople who could benefit from
it.
And there's still a lot ofpeople who aren't aware of it.
(21:33):
So you had actually shared thatarticle with me, comparing
awareness across different quoteunquote risk groups.
And, you know, indicated thateven though something like 90%
of MSM were aware of it, when Isay MSM, men who have sex with
men, I don't know if you'vecovered that already on your
podcast, define that acronym.
(21:55):
But by comparison, you know, itwas something like a quarter of
people who inject drugs wereaware of it and a much smaller
percentage of people who areheterosexual orientations,
heterosexual activity, wereaware of it.
So like there's still a lot ofunawareness that's out there and
needs to be remedied.
Valerie Earnshaw (22:12):
Okay.
So I'll, if we take all of theseissues, what we end up seeing is
so not only that, is there justnot a lot of people who are
accessing PrEP, but then whenyou take into like the provider
bias and then some peoplehaven't heard about it and all
these other things, we alsostart to see a lot of
disparities.
(22:33):
So you also shared with me, youknow, some, some work on those
disparities.
And I was really surprised, likeI know that racial and ethnic
disparities and health outcomesare everywhere, but this one
really knocked me over.
So of the folks who are sort ofcounted as eligible for PrEP of
the white folks were counted aseligible 42% of them, according
(22:53):
to the CDC data, the CDC datawere accessing it, or, you know,
had been prescribed it.
But then for black folks, thatwas 6%.
And for Latino folks, that was11%.
And I was just like, wow, thisis so terrible.
So we see racial and ethnicdisparities.
And then I also will highlightthat there are, you know, just
(23:14):
in the US there are a lot ofdisparities by geographic
location.
I was so surprised again, to seein Wyoming, it ranges from like
5% to New York where it's 41% ofpeople who are eligible are
receiving it, or, you know, are,have been prescribed, I suppose.
I had to peak at at DC for youand Delaware.
I mean, so DC, it's 37%, whichI, of course described to you
(23:38):
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 toour 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 thisproblem that not enough people
are accessing it.
Dr. Sarah Calabrese (24:07):
Yeah.
That is the case.
And there's disparities in termsof who is accessing, but also
who's aware of it, and also whoproviders are talking to about
it.
So there's also disparities interms of whether or not they
discussed with a provider andyou see differences.
So even though, you know, a highpercentage of MSM are aware of
PrEP, you see like racialdisparities among MSM in terms
(24:31):
of who's actually talking tothem about it.
So, so yeah, it's problem.
And I think that it's a problemthat could be helped by the sort
of broader roll-out of PrEP anda more sort of inclusive
messaging campaign.
Because I think right now, it'sjust, it's very targeted and as
(24:53):
a result, and it also relies alot on provider discretion.
And if we were to change somepolicies and change the
messaging approach so that likeeveryone is being made aware of
PrEP and even in a medicalsetting, everyone's being told
about PrEP and then they canmake informed decisions.
I just think that would go along way in terms of allowing
(25:14):
more people to be aware of itand 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 havefor birth control and other
things where it's like, this isa discussion that you have in
primary care and your optionsare laid out.
And I think you really hit on itearlier where the physician
shouldn't be trying to look atyou and you're out, like if you
(25:40):
have had sex with someone livingwith HIV in the last six months,
like ideally a provider shouldbe saying like,"well, here's
here is what it is here is whoam I be useful for?
What do you think?" And that's amuch more, as you've pointed out
in your writing, like it's amore patient centered approach
and it's also sort ofde-stigmatizing of PrEP.
Dr. Sarah Calabrese (26:03):
Right.
So, I mean, I think if providerswere talking about it with
everyone, that would go a longway towards normalizing and
de-stigmatizing, and I thinkthat you hit on it when you said
that, you know, it should reallybe the patient making informed
choices.
It's not up to the provider todecide like, what is best for
their sex life or theirrelationship life.
(26:23):
Like I believe that theprovider's role is really more
to form.
Maybe help them talk throughoptions and maybe help them to
evaluate their risk,"them" beingthe patient, and then continue
to care for them and providesupport while they are taking
PrEP.
I don't think it needs to bemore complicated than that.
And I think that's, what's donewith a lot of different types of
(26:45):
preventative medication or, youknow, different types of
treatment.
And so, like, it doesn't seemrational that we're not doing
the same with HIV and PrEP.
Valerie Earnshaw (26:52):
Right.
Right.
Okay.
So you teased this, we teasedthis a little bit earlier when
we said that you ran this earlystudy on providers and bias, and
you found some evidence thatbias might leak out to
prescription of PrEP.
That's a mouthful for everypresentation you've ever given.
Right.
So can we talk a little bit moreabout your work unpacking this
(27:15):
issue of what the providerbiases might be specifically
that are problematic, and howthey might be sort of impacting
whether, whether prescribers, itsounds like even like raise PrEP
as an issue, or raise PrEP as anoption with the patients that
they're seeing?
Dr. Sarah Calabrese (27:32):
Yeah.
I mean, so I can talk a littlebit about the line of work, that
or line of work that you'vereferenced.
So the initial study that we didtogether, which I described
somewhat previously, but it waswith a small sample of medical
students around a little over ahundred, and they were randomly
assigned to read a clinicalvignette that was either about a
(27:53):
black patient or a whitepatient.
Otherwise the clinical vignettewas totally the same.
It was about an MSM patient whowas at risk for HIV because he
was having condomless sex withhis partner.
He wanted a prescription forPrEP, and then they were asked
to make a series of clinicaljudgment about that patient and
ultimately indicate theirintention to prescribe PrEP for
(28:15):
him.
And so what came out of thatstudy and what we saw is that
the black patient was judged asmore likely to increase his
sexual risk-taking if he wasprescribed PrEP and that in turn
was associated with a lowerintention to prescribe.
So this kind of suggests that wehave this like indirect effect
(28:36):
of race on protective access toPrEP.
And so that prompted a couple ofother experimental studies that
were kind of in the same vein.
So there was a followup study.
We did again with medicalstudents and we didn't see the
same grace effect.
And we didn't see racism.
We also looked at or measuredracism of the medical students,
(28:57):
including both explicit, someaning how they reported their
attitudes on self-reportmeasure, as well as implicit
attitudes, we saw minimal impactof patient race, or medical
student racism on clinicaldecision making related to PrEP.
So, you know, it wasinconsistent with the first
study, but still like promisingfor society.
(29:19):
Good news in that study that wealso saw that heterosexism is
associated with clinicaljudgments about the patient.
And when I say hetero-sexism, Imean negative judgment of people
who are sexual minorities.
And so the more prejudiceagainst sexual minorities,
somebody was the more negative,the clinical judgment.
And this was again, related to areduced intention to prescribe
(29:42):
PrEP to the individual.
So as you know, we did a thirdstudy, which I was incorporating
your comments on last night, butwhere we looked at practicing
providers.
And so this was primary care andHIV care clinicians throughout
the US we changed the paradigm alittle bit.
(30:03):
So rather than having them reada vignette, we had them review
medical charts and wemanipulated key pieces of
information in the chart.
So again, we manipulated therace 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 wasa male patient, but a male
(30:27):
patient was either at riskbecause of sex with a woman
living with HIV, sex with a manliving with HIV, or because of
sharing needles, being aninjection drug user, and sharing
needles with a partner who hadHIV.
And so what really came out ofthat third study was this bias
related to people who injectdrugs.
(30:48):
So specifically, you know, inall cases, the patient was
described as seeking aprescription for PrEP.
The description was such that itwas very clear.
This would be a really goodcandidate for PrEP and it gave
background information aboutPrEP.
We talked about risk involved,like the relative risk of
different types of behaviors interms of HIV transmission, even
(31:12):
though all of these candidateswere really great candidates for
PrEP and all of them were doinga pretty responsible thing
because they were going to thehealthcare provider asking for
PrEP.
We still saw some differences inhow they were judged.
So the patient who injecteddrugs was judged as being less
responsible, less safetyconscious, and less likely to
(31:34):
adhere to PrEP if given aprescription for PrEP.
And then we saw that some ofthese judgments were again,
related to lower intention toprescribe to the patient.
So I would say collectivelythese three studies suggest that
really, I mean, they're allexperimental in nature, so
they're not documenting sort ofreal life bias and its impact,
(31:56):
but we specifically use anexperimental approach.
So we could really isolatedifferent forms of bias.
And I would say collectively,they suggest that provider
social biases can influenceclinical decision making related
to PrEP.
Valerie Earnshaw (32:10):
Yeah.
And when, whether or not someonehears about PrEP, has the
opportunity to learn about PrEP,and has the opportunity for PrEP
to be offered to them, hinges onwhether the provider raises it
in that clinical encounter.
If they're assuming that theperson is going to engage in
more risky sex, because they'rea black man, as opposed to a
(32:33):
white man.
And or if they think that thisperson who injects drugs is
going to be as adherent to PrEPas a person who doesn't inject
drugs- which just by the way,Chinazo Cunningham, who works a
great deal with people who usedrugs.
And she always brings up thatdrug 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 whoinject people who use drugs,
aren't less adherent to theirHIV medication, other things,
because they're good at usingdrugs.
But anyway, all of these likeideas, these perceptions that
providers have, becauseproviders are just people who
like the same stereotypes andideas as everyone else that if
(33:19):
it all rests on them, that,yeah, it's just, it's a
problematic piece where the stepof 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 pointedout that providers are just
people, because I thinksometimes when I'm talking about
provider biases, I feel like I'mvillainizing providers, when in
actuality we all have biases andyou know, they're no different
in that respect.
And so, I think that what wewant to do is implement policies
(33:51):
and strategies that can help toeither reduce those biases or
mitigate their effect on theirmental decision-making.
So, if we are allowing providerdiscretion to dictate who is
told about PrEP, andparticularly given that PrEP is
a situation where there isprovider discretion involved and
(34:12):
therefore the best course ofaction might be somewhat
ambiguous.
That's where biases- that opensthe door to personal biases.
Whereas if we were tellingproviders,"Listen just talk to
everyone about PrEP and, youknow, support them in making
their decision" then they're notsaying,"Hmm, this person's
risky.
This person's not, this person'sgoing to have an adherence
(34:32):
problem".
It takes the burden off them, itlike makes PrEP more accessible.
And it also, I mean, that is astressor, I think for providers,
not necessarily to think thatthey have bias, but to determine
the eligibility, that'ssomething that has come up in
research about barriers to PrEPprovision is, you know, concerns
(34:54):
about determining who iseligible for PrEP.
And so if we just kind ofshifted it, so it's like, apart
from these medical indicationsor Contra-indications, like
everyone is eligible, so justsupport them in making their
decision.
I think that could go a longway.
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 tome that like the burden of
having to figure out who'seligible, who's not, who may not
feel comfortable sharing likeinformation about eligibility,
like what kind of sex t hey'vebeen having or who they've been
having it with or who they'vebeen sharing needles with.
(35:33):
Like people may, people may notwant to share that with their
family doctor or if they're anadolescent, like their
pediatrician or things likethere's so many reasons and
doctors want to help people.
Right.
And so, yeah, that's a reallyinteresting perspective to feel
like that's a burden and yeah.
I mean, as a woman, I, when I gothrough routine like h ealthcare
(35:56):
now, it's like, I feel like Iwent in maybe for a bone scan.
And I think I was asked by likethree 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 ofreasons why people wouldn't want
to tell their providers or wouldn't raise it, that they've
experienced it.
(36:17):
And they're not going to be ableto look at me and tell somehow
that I would be someone w ho'sat risk of that.
So they're just, it's just ablanket policy, you know?
So enacting o r sort offollowing some of those
strategies within this arenacould be really beneficial.
Dr. Sarah Calabrese (36:34):
Yeah.
I mean, I think you're speakingto the fact that like even an
individual, they can onlypredict their own risk to some
extent.
Right.
Um, but they are better at doingthat than their provider.
Like really an individual is theexpert when it comes to their
own sexual lives, and theirplans, and like predicting
(36:54):
whether or not they're going tobe...
really, they should be the onesmaking the judgment call.
And, you know, also when itcomes to disclosing sensitive
information, it's easier, and Ithink that you alluded to this,
it's easier to disclose somebehaviors than others.
So as a heterosexual woman, likedisclosing sex with a man that
can be awkward, I don't have toworry about being discriminated
(37:17):
against for my sexualorientation.
Right.
And so it's the case that likesomebody who has a man who has
sex with men, like here's ahuge, additional hurdle that
they have to take a much biggerrisk in sharing that information
with a provider, because theydon't know how the provider
could react.
And if you think about sort ofintersectionality, right?
(37:38):
Like a black MSM has even morechallenges, you know, that they
have like additional pressurebecause they already feel like a
medical provider may judge thembased on their sex or their race
and men disclosing this otherminority status could seem like
an additional risk.
And so I, again, I think that Ialmost feel like risk behaviors
(38:01):
shouldn't have to be disclosed.
So let me sort of qualify that alittle bit.
Like, I think that in many casesit is helpful for a provider to
know about risk you're taking sothat they can help care for you
and like tailor their care andtreatment depending on what you
disclosed.
But when it comes to PrEP, itseems to make more sense to me
(38:26):
to just say like,"listen, thisis what PrEP protects against.
This is how it could bebeneficial.
Do you think that you couldbenefit from it?
Do you want to pursue it?" Andthen if the patient wants to
like delve into, well,"I'mhaving sex with a man and a
woman" that's their business andthey could disclose that and
maybe that will help with otheraspects of care, but when it
(38:46):
comes to just like, who shouldaccess PrEP and who's not, it
isn't the case that like onlymen who have sex with men are
only like everybody who has sexand could benefit from PrEP.
So like, why are we making thesedistinctions or like forcing
patients to make thoseuncomfortable disclosures.
Valerie Earnshaw (39:07):
Yeah.
Okay.
Sarah.
Well, I would be really remissif I let you out of this podcast
recording without bringing upsexual pleasure.
So, when I read your writingabout PrEP, especially, you
know, you had this really lovelycommentary in the American
journal of public health aboutPrEP and stigma.
(39:27):
You write quite a bit aboutsexual 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 yourbrain a little bit around why is
sexual pleasure left out of theconversation around PrEP and why
(39:48):
is it important to bring it up?
Dr. Sarah Calabrese (39:51):
Yeah.
So thank you for your kind wordsabout my commentary.
Yeah.
In terms of why it's notdiscussed more.
So, I mean, I think in general,when we think about science and
scientific discourse, there'smuch more of an emphasis on kind
of pathology and diseaseprevention than there is about
(40:11):
kind of more positive dimensionsof sexual health and wellbeing.
So I think that, you know, therehas been an emphasis on
protection against HIV without akind of corresponding
recognition of the benefits tosexual health, the form of
pleasure and other types ofcentral social benefits.
Pleasure is important becauseit's an aspect of sexual health
(40:34):
and sexual health is importantbecause it's part of our whole
health.
And so it's something that Ithink 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 thebenefit of PrEP for them and
(40:55):
then have more fulfilling sexuallives.
And, you know, not just in termsof pleasure in terms of like
physical sensation, but alsolike in terms of feeling
intimacy, feeling less anxiety,some more enjoyment during sex.
And also it might open uprelationship possibilities for
people who have previouslyavoided different relationships,
(41:18):
avoided being in relationshipswith people who are living with
HIV because of fear oftransmission.
Like this can make them morecomfortable and this can make it
less of an issue in coupleswhere one person has HIV and the
other person doesn't.
So like there's so many andpleasure is so important.
And, you know, I think that weneed to change the paradigm a
little bit, but I, I think thatpart of it is something that
(41:42):
should be driven from the top interms of when it comes to
funding.
And when it comes to scientificjournals.
They should be making this moreof a priority.
So I was thrilled to see acouple of years ago, the
American journal of publichealth did kind of a special
section about pleasure and howthat was important to health.
(42:04):
And so, you know, they made thatsomething that they demonstrated
that that was something that'simportant issue and a priority
to them.
And I think when it comes tofunding, for example, a lot of
researchers go to the nationalinstitutes of health and it
would be great if they put out acall for research that focused
on enhancing sexual pleasure,instead of just like, oftentimes
(42:29):
it seems more about diseaseprevention.
And so it would be great ifthere was kind of a change in
thinking at the top, because Ithink that could also filter
down in terms of the sciencethat we actually do and the
research questions that westrive to answer.
Valerie Earnshaw (42:43):
Absolutely.
Oh, Sarah, you're such a greatexample of someone I think, who
feels really passionately aboutan area and someone who has
really focused on trying tounderstand a problem what's
happening with that problem.
And then identifying very doablesolutions.
(43:04):
I think that this is soimportant because there are so
many disparities, you know, whenit comes to PrEP and there's
just so much work that needs tobe done when only 18%, but
probably a lot fewer people whoare eligible for PrEP or who
could benefit from PrEP areactually accessing it.
(43:26):
It's a huge problem.
So just want to say, thank youfor all the excellent work
you're doing in this area.
Thank you for having me alongfor some of that work.
And in particular, thank youtoday 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 drawingattention to this issue and some
of my work and thank you for allyour contributions to the
research that we've donetogether.
I'm looking forward tocontinuing to collaborate on
that stuff.
Valerie Earnshaw (43:52):
You're so nice.
Cause you always refer to it asthe work we're doing together,
but I want every listener toknow that this is like Sarah
Calabrese, and like Valerie backin the wing.
So it's really generous thatyou've included me and I love
working on it with you andthinking about it.
So thank you.
Thank you.
Thanks to the Stigma and HealthInequities Lab at the University
(44:13):
of Delaware for their help atthe podcast, including Saray
Lopez, Molly Marine, JamesWallace, 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 clickingsubscribe.
Valerie Earnshaw (44:28):
Thanks to all of you for listening.
(45:04):
[inaudible].
I'm Valerie Earnshaw.
Carly Hill (00:13):
I'm Carly Hill.
Valerie Earnshaw (00:14):
and this is Sex Drugs and Science.
Carly Hill (00:17):
Today's conversation is with Sarah Calabrese, who is
an assistant Professor ofPsychology at George Washington
University.
Her research focuses on sexualhealth promotion among racial
and sexual minorities and othersocially marginalized groups.
Valerie Earnshaw (00:32):
A key part of Sarah's work aims to identify
and address barriers to HIVprevention, including
pre-exposure prophylaxis orPrEP.
So PrEP is a daily pill that canbe taken to prevent HIV.
It's actually a really importantmedication.
It's super promising in reducingthe spread of HIV.
But interestingly enough, not alot of people are taking it.
(00:54):
So we try to understand why morepeople aren't taking PrEP when
we taught it with Sarah.
Carly Hill (01:00):
And you guys will notice for this episode that I
am missing.
I got into a little fenderbender on the way to record the
podcast, but I, you know, knewthat Valerie could somehow
handle the show without me.
So I think you'll find she did agreat job.
Valerie Earnshaw (01:16):
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 complaintsthat way, but anyway, Carly, we
super miss you, super glad thateverything's okay.
And we hope that everyone outthere enjoys this conversation
(01:39):
with Sarah Calabrese.
All right.
Dr.
Calabrese is thanks for joiningus on the podcast.
Dr. Sarah Calabrese (01:51):
I'm happy to be here.
Thanks for having me.
Valerie Earnshaw (01:53):
So, Sarah, you received your PhD in clinical
psych from George Washingtonuniversity.
And I realized that althoughwe've known each other for
almost a decade now, and also, Ifeel like I could order for you
at sushi.
We,'ve had our sushi dates, thatI actually don't know, like the
(02:16):
backstory in terms of why youdecided to pursue clinical psych
specifically.
Dr. Sarah Calabrese (02:22):
Yeah.
So in college I was a doublemajor in biology and psychology
and the original plan was to gointo medicine.
I became very interested inpsychological science and kind
of how psychological processesrelated to health.
And so for that reason, clinicalpsych seems like a good fit.
And the idea of a clinical psychPhD was desirable because I
(02:45):
would get training in bothresearch as well as clinical
work, if I wanted to go downthat path, which I wasn't sure
about at the time.
So also I think that medicinewould have been a terrible thing
for me in retrospect, becauseI'm super squeamish.
And so I think this is reallythe best way to go.
Valerie Earnshaw (03:03):
That's awesome.
That's really interesting thatyou were interested in medicine.
I didn't know that.
And that makes sense.
I mean, we'll talk about thismore, but you've developed this
big interest in this likebiomedical technology, this
like, PrEP, which is an HIVprevention pill, so, or HIV
prevention medication, eventhough you didn't pursue the MD,
(03:25):
you're still like very muchworking in that area.
So,
Dr. Sarah Calabrese (03:28):
And also studying MDs.
Right?
A lot of my work is aroundhealthcare providers and
provider bias.
So yeah, I guess I didn'ttotally get away from medicine.
Valerie Earnshaw (03:41):
So when you were in your grad program, it
sounds like your particular gradprogram was like a really
terrific fit for you because youwere in the clinical psych
program at George Washington.
And there are a bunch of folkswho have this interest in
science and medicine.
And I saw that you worked on astudy of HIV medication
(04:01):
adherence and disclosure whileyou were a grad student.
So is that where your like,interest in HIV started to
percolate?
Dr. Sarah Calabrese (04:07):
So I think my interest in HIV really
started back in college, likegoing into grad school, you
know, you apply to work with aparticular mentor.
And so I applied to work withDr.
Maria Cecilia Zea because of thework that she was doing around
understanding HIV risk andprevention with Latino MSM.
So the interest in HIV startedprior to that, and it was just,
(04:30):
it's always been something thatI've gravitated towards.
I think a lot of people havethese 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 partof that is recognition that it
disproportionately affectscommunities that are already
(04:53):
disadvantaged, recognizing thatthat was a social problem.
And then I think also there wasintellectual curiosity because
on the one hand we hadprevention tools that we knew
worked.
And so in theory, HIV could beprevented and yet, clearly it
wasn't being prevented.
The spread was still happening.
(05:14):
And so I wanted to understandwhat the barriers were to the
use of existing tools.
So I think that's kind of wheremy interest in HIV came from.
And then when I went to gradschool, I went specifically to
work with Maria Cecilia andthen, yeah, I mean, as he spoke
to, it was a good fit in termsof the work people were doing
there.
And other people were interestedin work that was really more
(05:37):
community focused and appliedhealth.
And so all of those thingsappeal to me.
Valerie Earnshaw (05:42):
It's really interesting hearing you talk
about it because I think I waslike attracted to studying HIV
in grad school for similarreasons.
You know, I think I developed myinterest in stigma earlier, but
then HIV is just such like aperfect playing field to study
stigma, all of these socialdynamics or health disparities.
(06:04):
I mean, HIV is terrible.
That it's the case, but becausethere are so many disparities
because of some of these issuesthat you're highlighting around,
you know, we know what stops HIVtransmission, why is it
happening?
You know, it's reallyinteresting place to work, I
think, as the scientists, butmaybe even, especially like as a
social scientist.
Dr. Sarah Calabrese (06:22):
Yeah, yeah.
Like really understanding someof those social factors and
social processes that arecontributing to the spread.
Valerie Earnshaw (06:29):
Yeah.
Yeah.
All right.
Well then both of our pathsconverge, when we were post-
docs.
So we both did the post-doctoralfellowship at the center for
interdisciplinary research onaids at Yale university.
And as I was thinking throughyour timeline, I was like, oh
wow, because you were a post-docat this really fantastic place
(06:53):
to, you know, study HIV and digin to HIV research.
Although you had started thatearlier, but at the same time
that PrEP is approved by theFDA.
So is that then where theinterest in PrEP starts to
emerge or where had you beeninterested in it beforehand?
Because the trials for it hadbeen going on for some years
(07:13):
before FDA gave the green lightfor folks to use it.
Dr. Sarah Calabrese (07:17):
Yeah.
I mean, I think that my interestreally took off sort of, end of
grad school, beginning of postdoc.
You know, it really coincidedwith the release of the results
from iPrEx and the, which is aclinical efficacy study, as well
as other clinical studies andthen FDA approval in 2012.
(07:37):
That was all around the timethat I was doing my postdoc.
And I think in grad school PrEPwas on the radar and particular
microbicides, but it was reallyat the time I wasn't doing work
related to that.
It was really kind of once thetrial results were released that
looked so promising once FDAapproval occurred and PrEP just
(07:59):
seemed fantastic.
PrEP is fantastic, but you know,it really just seemed like this
game changer or like all of asudden we've been struggling to
curb the spread of HIV becauseof X, Y, and Z reasons.
And like, we keep trying to pushthese other prevention methods,
but clearly it's not enough.
And then like suddenly PrEPcomes on the scene and it
(08:19):
circumvents so many of thechallenges associated with other
prevention options.
And so how could you not getexcited about that?
I think that, you know, myresearch is just kind of moving
with the science and it was ingrad school, as you know, that I
did that, we did that initialstudy where we looked at medical
students and their clinicaljudgment and clinical
(08:44):
decision-making related to PrEPand how it may differ according
to the race of the patient andgetting those initial results
that suggested that biases couldcome into play when it came
prescribing PrEP.
And that could have implicationsfor access.
I think that really just laidthe foundation for my subsequent
research trajectory.
Valerie Earnshaw (09:06):
Arc is lit.
I remember going to a conferencewith you in New York city.
I don't remember much about theconference, but I do remember
sitting at these like longtables with you.
And you were thinking about thatstudy and you were talking it
through out loud and sometimes,you know, you talk to people
about their research ideas andyou're like, I don't know if you
(09:29):
are really into this part, youknow, but you were like, you
were all lit up about it.
You like follow that this, thatyou were like really excited
about it.
And oftentimes, you know, you,you leave the conference, you
leave the room and you don't dothe study, but you did the
study, and then some, which islike really amazing.
So I'll have to come back to themethods of that.
Dr. Sarah Calabrese (09:47):
I was thinking about that conference
as well.
I think that's really where theidea initially you took off.
And I remember you being therereally encouraging me.
And I think that you wereinstrumental in me actually
carrying out the study becauseyou 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 beexcited and encouraging of like
a really excellent idea.
So I'll just wrap up the careertrajectory part and then I'll
push us to talk more about likewhat PrEP actually is, because
I'm sure some folks arewondering.
But I just want to mention thatafter postdoc and a few
additional years at Yale, thatyou returned to GW, George
(10:29):
Washington University as afaculty member in 2016.
And I just want to put out therethat that's quite remarkable
because many graduate students,when they're doing their
training, there, they're verymuch warned that it is difficult
to be hired by the departmentthat trained you.
You'll never say this, but it'squite a big deal.
And it really speaks to thequality of your work, I think,
(10:52):
that your department wanted youback 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 justreally 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 thatwas knowing the department and
knowing the program is why itwas such a big draw for me as
well.
Like just having thatfamiliarity, knowing who my
colleagues would be, knowing thekind of work people were doing,
the environment, the setting,DC, all of it.
It's just, I enjoyed it in gradschool.
(11:29):
And I was really excited to havethe opportunity to come back.
Valerie Earnshaw (11:32):
Yeah.
It's a really phenomenaldepartment for people,
especially like you who havethis interest in inequity,
social factors, crossovers withlike medicine and, and health.
It's like, it's a, it's a prettyunique psychology department in
that way.
Dr. Sarah Calabrese (11:49):
It really is.
I don't know how many psychologydepartments my stuff would
really fit in.
And GW just struck me as sounique because as I said, there
really is an intersection ofpsychology and public health.
And particularly is related, alot of people do work related to
HIV in our department, but alsoat GW there is a NIH funded
(12:10):
center that's based in GW andencompasses many institutions in
DC.
So like, it's really a idealplace to be doing HIV research.
Valerie Earnshaw (12:20):
Yeah.
Okay.
So now we've been talking aboutit for like 15 minutes.
So maybe we could talk aboutwhat PrEP is for folks who may
not be familiar with it.
Maybe think about who iseligible for PrEP.
Cause not everyone is prescribedPrEP, although maybe they should
be, but
Dr. Sarah Calabrese (12:38):
Yes.
So PrEP is Pre-exposureProphylaxis and it is medication
that is taken on an ongoingbasis by somebody who is HIV
negative in order to prevent theacquisition of HIV.
It's incredibly effective, atleast 99%, which, I mean, that's
just unreal.
That's- people hesitate or youknow object, to calling it a
(13:02):
silver bullet, but I don'tunderstand why we don't, it
feels like it is! Currently theform of PrEP that is FDA
approved is a once a day pill.
There's a couple of differentformulations, but there are
other dosing and deliverystrategies that are kind of in
the pipeline, event-drivendosing, where you're not taking
medication every day, but you'retaking it around the time of a
(13:25):
potential transmission event.
There's also different deliverystrategies that are in a lot of
ways sort of like birth control.
So there's injections, there'simplants, there's rings, et
cetera.
So, you know, these are variousstages of testing and
development, but I think thatit's very promising in terms of
what might be available down theline.
(13:46):
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 allthe, like all the various ways
that it could come out, downthe, down the line, especially
like as women or as I'll just doto myself, like as a woman,
having so many options for birthcontrol is really helpful, you
know, and different things workbest for different people.
So the idea that there's goingto 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 abouteligibility.
So this is maybe a controversialissue.
I mean, it's something that isapproved for US adults who are
at risk because of their sexualbehavior or because of their
injection drug practices, forexample, sharing needles.
(14:34):
Those are the people who couldbenefit from it.
And it's also available, Ishould say, not just adults, but
adolescents as well.
There are various sort ofcriteria and guidelines that
have been put out there, which Igenerally 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, plushave had anal or vaginal sex in
the past six months, plus have asexual partner with HIV, or is
someone who doesn't consistentlyuse condoms, or someone who has
been diagnosed with an STD inthe past six months." So that's,
(15:12):
that's like the sexualtransmission route.
And then for people who injectdrugs, it's"if you have an
injection partner, so you'resharing needles with someone who
has HIV or if you kind ofgenerally share injection
equipment.
So maybe you're sharing, youknow, needles or injection
equipment with someone who hasHIV." So, okay.
So those criteria for who iseligible to PrEP sound rather
(15:34):
conservative to you.
So please, please tell me whythey sound conservative.
Dr. Sarah Calabrese (15:38):
Yeah.
So I think my concerns, there'stwo ways of thinking about it.
So one is how the criteria areused 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 ofclinicians use them as
guidelines, to determine who totalk about PrEP with.
And so, you know, to the extentthey are unaware of patient's
(16:02):
behavior, or patients' needs, orpatients behavioral goals, like
they may or may not be talkingto a given patient, even though
the patient could potentiallybenefit.
In terms of what is actually inthe criteria.
We know that past behavior doesnot necessarily predict future
behavior.
And so the fact that somebodyhas had condom-less sex with a
(16:25):
partner of unknown statusmultiple times in the last six
months doesn't mean anythingabout the next six months or
their plans for the next sixmonths.
So I think using past behavioras an indicator can be
problematic.
I think it also warrantsconsideration, the fact that
this is really private,sensitive information about a
patient that you are potentiallyasking about or thinking about.
(16:49):
And so patients may or may notprovide that information to
their providers.
Understandably so, and they maynot be motivated to share
intimate details of their sexlife when they don't realize
that being informed about PrEPis contingent on their doing so,
like they may not reallyperceive a benefit in sharing
that information with theirprovider.
(17:10):
And so I think that having theprovider be the decision maker
about who gets to hear aboutPrEP, that is a problem.
And I think that the criteriathemselves, there are somewhat
complicated.
They depend on individual levelbehavior.
It's been shown that this canactually lead to disparities in
(17:30):
terms of who's eligible.
So for example, black Americanshave been less likely to be
deemed eligible than whiteAmericans in some studies.
And that may be because theirrisk factors being less about
individual level behavior andmore about sort of networks or
communities.
I think the criteria that hadbeen used are in need of reform,
(17:53):
but I will also say the CDC isreforming 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 guidelinesthat are posted online and there
are webinars where they areinviting public comment next
week, who knows what the nextedition or iteration might be.
But I did note in the draft thatthey were suggesting, talking
about PrEP with all sexuallyactive adults.
So that's a step in the rightdirection.
(18:22):
I'd still like to see somechanges with that, but it's
better than what we havealready.
So perhaps they're evolving.
Valerie Earnshaw (18:29):
Yeah.
So one of the things we're kindof digging into a little bit
this season, Sarah is around theintersection of like of
scientists and policies.
So, I mean, you were able totell me exactly like when these
meetings are so as a scientist,like, do you plan to get
feedback?
Do you plan to participate inthese?
Like, are you trying to shareyour expertise, with the CDC as
(18:51):
they are- in a perfect world,they would come to you.
Right.
But, they don't usually come tous.
So are you trying to like speakup 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 whatI'm going to say.
And I think it's important toattend these kinds of things.
If you want to have an impactthey're not accepting public
comment otherwise, so that wouldbe the place to do it.
When the US preventative taskforce was developing their PrEP
guidelines.
I wrote a letter and outlinedthe reasons, that I thought that
(19:26):
these criteria should be X, Y,and Z or changed.
And I have made some smallefforts in that respect, but I
don't think that I've beenconsistent about contacting
specific branch of the CDC withmy ideas.
You know, I publish on them, butI could probably do more.
Valerie Earnshaw (19:41):
No, but I mean, I think it's great even
that you are writing lettersthat when the opportunity, when
the CDC says,"Hey, we'relistening", you're like,"All
right, buckle up.
I'm coming." I think that whenthere are opportunities, like
what are you going to do driveto 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'snot going to count towards your
promotion and tenure to talkabout your advocacy work with
the CDC.
So anyway, I think that'sawesome.
I think it's great that youthink about, you know, speaking
up.
Okay.
So to take us back to some ofthese issues around why it's
important to revise some ofthese guidelines, it seems like
(20:24):
a lot of people who couldbenefit from PrEP, aren't
actually receiving it.
So some data that you sharedwith me before this recording
was that there are estimated tobe at least 1.8 million people
in the US who would be eligiblefor PrEP, but only 18.1% of them
have been prescribed it.
So I, I continue to think thatthat's bananas.
(20:48):
I mean, that's a pretty smalllike group of people who could
benefit by this.
And we're talking aboutbenefiting from it, from these
like conservative eligibilitycriteria.
Right.
So if we, if we've thoughtthrough that even more, there's
probably like a lot more peoplewho could benefit from, so the
percentage of people getting it,who could, who could be helped
(21:08):
from it is quite small,
Dr. Sarah Calabrese (21:11):
Right?
Yeah.
So it's probably the case thatthe percentage is much smaller
than 18%.
If you're taking intoconsideration the full gamut of
people who could benefit fromit.
And I think that part of thereason for that is that it's not
being made available to otherpeople who could benefit from
it.
And there's still a lot ofpeople who aren't aware of it.
(21:33):
So you had actually shared thatarticle with me, comparing
awareness across different quoteunquote risk groups.
And, you know, indicated thateven though something like 90%
of MSM were aware of it, when Isay MSM, men who have sex with
men, I don't know if you'vecovered that already on your
podcast, define that acronym.
(21:55):
But by comparison, you know, itwas something like a quarter of
people who inject drugs wereaware of it and a much smaller
percentage of people who areheterosexual orientations,
heterosexual activity, wereaware of it.
So like there's still a lot ofunawareness that's out there and
needs to be remedied.
Valerie Earnshaw (22:12):
Okay.
So I'll, if we take all of theseissues, what we end up seeing is
so not only that, is there justnot a lot of people who are
accessing PrEP, but then whenyou take into like the provider
bias and then some peoplehaven't heard about it and all
these other things, we alsostart to see a lot of
disparities.
(22:33):
So you also shared with me, youknow, some, some work on those
disparities.
And I was really surprised, likeI know that racial and ethnic
disparities and health outcomesare everywhere, but this one
really knocked me over.
So of the folks who are sort ofcounted as eligible for PrEP of
the white folks were counted aseligible 42% of them, according
(22:53):
to the CDC data, the CDC datawere accessing it, or, you know,
had been prescribed it.
But then for black folks, thatwas 6%.
And for Latino folks, that was11%.
And I was just like, wow, thisis so terrible.
So we see racial and ethnicdisparities.
And then I also will highlightthat there are, you know, just
(23:14):
in the US there are a lot ofdisparities by geographic
location.
I was so surprised again, to seein Wyoming, it ranges from like
5% to New York where it's 41% ofpeople who are eligible are
receiving it, or, you know, are,have been prescribed, I suppose.
I had to peak at at DC for youand Delaware.
I mean, so DC, it's 37%, whichI, of course described to you
(23:38):
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 toour 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 thisproblem that not enough people
are accessing it.
Dr. Sarah Calabrese (24:07):
Yeah.
That is the case.
And there's disparities in termsof who is accessing, but also
who's aware of it, and also whoproviders are talking to about
it.
So there's also disparities interms of whether or not they
discussed with a provider andyou see differences.
So even though, you know, a highpercentage of MSM are aware of
PrEP, you see like racialdisparities among MSM in terms
(24:31):
of who's actually talking tothem about it.
So, so yeah, it's problem.
And I think that it's a problemthat could be helped by the sort
of broader roll-out of PrEP anda more sort of inclusive
messaging campaign.
Because I think right now, it'sjust, it's very targeted and as
(24:53):
a result, and it also relies alot on provider discretion.
And if we were to change somepolicies and change the
messaging approach so that likeeveryone is being made aware of
PrEP and even in a medicalsetting, everyone's being told
about PrEP and then they canmake informed decisions.
I just think that would go along way in terms of allowing
(25:14):
more people to be aware of itand 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 havefor birth control and other
things where it's like, this isa discussion that you have in
primary care and your optionsare laid out.
And I think you really hit on itearlier where the physician
shouldn't be trying to look atyou and you're out, like if you
(25:40):
have had sex with someone livingwith HIV in the last six months,
like ideally a provider shouldbe saying like,"well, here's
here is what it is here is whoam I be useful for?
What do you think?" And that's amuch more, as you've pointed out
in your writing, like it's amore patient centered approach
and it's also sort ofde-stigmatizing of PrEP.
Dr. Sarah Calabrese (26:03):
Right.
So, I mean, I think if providerswere talking about it with
everyone, that would go a longway towards normalizing and
de-stigmatizing, and I thinkthat you hit on it when you said
that, you know, it should reallybe the patient making informed
choices.
It's not up to the provider todecide like, what is best for
their sex life or theirrelationship life.
(26:23):
Like I believe that theprovider's role is really more
to form.
Maybe help them talk throughoptions and maybe help them to
evaluate their risk,"them" beingthe patient, and then continue
to care for them and providesupport while they are taking
PrEP.
I don't think it needs to bemore complicated than that.
And I think that's, what's donewith a lot of different types of
(26:45):
preventative medication or, youknow, different types of
treatment.
And so, like, it doesn't seemrational that we're not doing
the same with HIV and PrEP.
Valerie Earnshaw (26:52):
Right.
Right.
Okay.
So you teased this, we teasedthis a little bit earlier when
we said that you ran this earlystudy on providers and bias, and
you found some evidence thatbias might leak out to
prescription of PrEP.
That's a mouthful for everypresentation you've ever given.
Right.
So can we talk a little bit moreabout your work unpacking this
(27:15):
issue of what the providerbiases might be specifically
that are problematic, and howthey might be sort of impacting
whether, whether prescribers, itsounds like even like raise PrEP
as an issue, or raise PrEP as anoption with the patients that
they're seeing?
Dr. Sarah Calabrese (27:32):
Yeah.
I mean, so I can talk a littlebit about the line of work, that
or line of work that you'vereferenced.
So the initial study that we didtogether, which I described
somewhat previously, but it waswith a small sample of medical
students around a little over ahundred, and they were randomly
assigned to read a clinicalvignette that was either about a
(27:53):
black patient or a whitepatient.
Otherwise the clinical vignettewas totally the same.
It was about an MSM patient whowas at risk for HIV because he
was having condomless sex withhis partner.
He wanted a prescription forPrEP, and then they were asked
to make a series of clinicaljudgment about that patient and
ultimately indicate theirintention to prescribe PrEP for
(28:15):
him.
And so what came out of thatstudy and what we saw is that
the black patient was judged asmore likely to increase his
sexual risk-taking if he wasprescribed PrEP and that in turn
was associated with a lowerintention to prescribe.
So this kind of suggests that wehave this like indirect effect
(28:36):
of race on protective access toPrEP.
And so that prompted a couple ofother experimental studies that
were kind of in the same vein.
So there was a followup study.
We did again with medicalstudents and we didn't see the
same grace effect.
And we didn't see racism.
We also looked at or measuredracism of the medical students,
(28:57):
including both explicit, someaning how they reported their
attitudes on self-reportmeasure, as well as implicit
attitudes, we saw minimal impactof patient race, or medical
student racism on clinicaldecision making related to PrEP.
So, you know, it wasinconsistent with the first
study, but still like promisingfor society.
(29:19):
Good news in that study that wealso saw that heterosexism is
associated with clinicaljudgments about the patient.
And when I say hetero-sexism, Imean negative judgment of people
who are sexual minorities.
And so the more prejudiceagainst sexual minorities,
somebody was the more negative,the clinical judgment.
And this was again, related to areduced intention to prescribe
(29:42):
PrEP to the individual.
So as you know, we did a thirdstudy, which I was incorporating
your comments on last night, butwhere we looked at practicing
providers.
And so this was primary care andHIV care clinicians throughout
the US we changed the paradigm alittle bit.
(30:03):
So rather than having them reada vignette, we had them review
medical charts and wemanipulated key pieces of
information in the chart.
So again, we manipulated therace 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 wasa male patient, but a male
(30:27):
patient was either at riskbecause of sex with a woman
living with HIV, sex with a manliving with HIV, or because of
sharing needles, being aninjection drug user, and sharing
needles with a partner who hadHIV.
And so what really came out ofthat third study was this bias
related to people who injectdrugs.
(30:48):
So specifically, you know, inall cases, the patient was
described as seeking aprescription for PrEP.
The description was such that itwas very clear.
This would be a really goodcandidate for PrEP and it gave
background information aboutPrEP.
We talked about risk involved,like the relative risk of
different types of behaviors interms of HIV transmission, even
(31:12):
though all of these candidateswere really great candidates for
PrEP and all of them were doinga pretty responsible thing
because they were going to thehealthcare provider asking for
PrEP.
We still saw some differences inhow they were judged.
So the patient who injecteddrugs was judged as being less
responsible, less safetyconscious, and less likely to
(31:34):
adhere to PrEP if given aprescription for PrEP.
And then we saw that some ofthese judgments were again,
related to lower intention toprescribe to the patient.
So I would say collectivelythese three studies suggest that
really, I mean, they're allexperimental in nature, so
they're not documenting sort ofreal life bias and its impact,
(31:56):
but we specifically use anexperimental approach.
So we could really isolatedifferent forms of bias.
And I would say collectively,they suggest that provider
social biases can influenceclinical decision making related
to PrEP.
Valerie Earnshaw (32:10):
Yeah.
And when, whether or not someonehears about PrEP, has the
opportunity to learn about PrEP,and has the opportunity for PrEP
to be offered to them, hinges onwhether the provider raises it
in that clinical encounter.
If they're assuming that theperson is going to engage in
more risky sex, because they'rea black man, as opposed to a
(32:33):
white man.
And or if they think that thisperson who injects drugs is
going to be as adherent to PrEPas a person who doesn't inject
drugs- which just by the way,Chinazo Cunningham, who works a
great deal with people who usedrugs.
And she always brings up thatdrug 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 whoinject people who use drugs,
aren't less adherent to theirHIV medication, other things,
because they're good at usingdrugs.
But anyway, all of these likeideas, these perceptions that
providers have, becauseproviders are just people who
like the same stereotypes andideas as everyone else that if
(33:19):
it all rests on them, that,yeah, it's just, it's a
problematic piece where the stepof 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 pointedout that providers are just
people, because I thinksometimes when I'm talking about
provider biases, I feel like I'mvillainizing providers, when in
actuality we all have biases andyou know, they're no different
in that respect.
And so, I think that what wewant to do is implement policies
(33:51):
and strategies that can help toeither reduce those biases or
mitigate their effect on theirmental decision-making.
So, if we are allowing providerdiscretion to dictate who is
told about PrEP, andparticularly given that PrEP is
a situation where there isprovider discretion involved and
(34:12):
therefore the best course ofaction might be somewhat
ambiguous.
That's where biases- that opensthe door to personal biases.
Whereas if we were tellingproviders,"Listen just talk to
everyone about PrEP and, youknow, support them in making
their decision" then they're notsaying,"Hmm, this person's
risky.
This person's not, this person'sgoing to have an adherence
(34:32):
problem".
It takes the burden off them, itlike makes PrEP more accessible.
And it also, I mean, that is astressor, I think for providers,
not necessarily to think thatthey have bias, but to determine
the eligibility, that'ssomething that has come up in
research about barriers to PrEPprovision is, you know, concerns
(34:54):
about determining who iseligible for PrEP.
And so if we just kind ofshifted it, so it's like, apart
from these medical indicationsor Contra-indications, like
everyone is eligible, so justsupport them in making their
decision.
I think that could go a longway.
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 tome that like the burden of
having to figure out who'seligible, who's not, who may not
feel comfortable sharing likeinformation about eligibility,
like what kind of sex t hey'vebeen having or who they've been
having it with or who they'vebeen sharing needles with.
(35:33):
Like people may, people may notwant to share that with their
family doctor or if they're anadolescent, like their
pediatrician or things likethere's so many reasons and
doctors want to help people.
Right.
And so, yeah, that's a reallyinteresting perspective to feel
like that's a burden and yeah.
I mean, as a woman, I, when I gothrough routine like h ealthcare
(35:56):
now, it's like, I feel like Iwent in maybe for a bone scan.
And I think I was asked by likethree 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 ofreasons why people wouldn't want
to tell their providers or wouldn't raise it, that they've
experienced it.
(36:17):
And they're not going to be ableto look at me and tell somehow
that I would be someone w ho'sat risk of that.
So they're just, it's just ablanket policy, you know?
So enacting o r sort offollowing some of those
strategies within this arenacould be really beneficial.
Dr. Sarah Calabrese (36:34):
Yeah.
I mean, I think you're speakingto the fact that like even an
individual, they can onlypredict their own risk to some
extent.
Right.
Um, but they are better at doingthat than their provider.
Like really an individual is theexpert when it comes to their
own sexual lives, and theirplans, and like predicting
(36:54):
whether or not they're going tobe...
really, they should be the onesmaking the judgment call.
And, you know, also when itcomes to disclosing sensitive
information, it's easier, and Ithink that you alluded to this,
it's easier to disclose somebehaviors than others.
So as a heterosexual woman, likedisclosing sex with a man that
can be awkward, I don't have toworry about being discriminated
(37:17):
against for my sexualorientation.
Right.
And so it's the case that likesomebody who has a man who has
sex with men, like here's ahuge, additional hurdle that
they have to take a much biggerrisk in sharing that information
with a provider, because theydon't know how the provider
could react.
And if you think about sort ofintersectionality, right?
(37:38):
Like a black MSM has even morechallenges, you know, that they
have like additional pressurebecause they already feel like a
medical provider may judge thembased on their sex or their race
and men disclosing this otherminority status could seem like
an additional risk.
And so I, again, I think that Ialmost feel like risk behaviors
(38:01):
shouldn't have to be disclosed.
So let me sort of qualify that alittle bit.
Like, I think that in many casesit is helpful for a provider to
know about risk you're taking sothat they can help care for you
and like tailor their care andtreatment depending on what you
disclosed.
But when it comes to PrEP, itseems to make more sense to me
(38:26):
to just say like,"listen, thisis what PrEP protects against.
This is how it could bebeneficial.
Do you think that you couldbenefit from it?
Do you want to pursue it?" Andthen if the patient wants to
like delve into, well,"I'mhaving sex with a man and a
woman" that's their business andthey could disclose that and
maybe that will help with otheraspects of care, but when it
(38:46):
comes to just like, who shouldaccess PrEP and who's not, it
isn't the case that like onlymen who have sex with men are
only like everybody who has sexand could benefit from PrEP.
So like, why are we making thesedistinctions or like forcing
patients to make thoseuncomfortable disclosures.
Valerie Earnshaw (39:07):
Yeah.
Okay.
Sarah.
Well, I would be really remissif I let you out of this podcast
recording without bringing upsexual pleasure.
So, when I read your writingabout PrEP, especially, you
know, you had this really lovelycommentary in the American
journal of public health aboutPrEP and stigma.
(39:27):
You write quite a bit aboutsexual 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 yourbrain a little bit around why is
sexual pleasure left out of theconversation around PrEP and why
(39:48):
is it important to bring it up?
Dr. Sarah Calabrese (39:51):
Yeah.
So thank you for your kind wordsabout my commentary.
Yeah.
In terms of why it's notdiscussed more.
So, I mean, I think in general,when we think about science and
scientific discourse, there'smuch more of an emphasis on kind
of pathology and diseaseprevention than there is about
(40:11):
kind of more positive dimensionsof sexual health and wellbeing.
So I think that, you know, therehas been an emphasis on
protection against HIV without akind of corresponding
recognition of the benefits tosexual health, the form of
pleasure and other types ofcentral social benefits.
Pleasure is important becauseit's an aspect of sexual health
(40:34):
and sexual health is importantbecause it's part of our whole
health.
And so it's something that Ithink 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 thebenefit of PrEP for them and
(40:55):
then have more fulfilling sexuallives.
And, you know, not just in termsof pleasure in terms of like
physical sensation, but alsolike in terms of feeling
intimacy, feeling less anxiety,some more enjoyment during sex.
And also it might open uprelationship possibilities for
people who have previouslyavoided different relationships,
(41:18):
avoided being in relationshipswith people who are living with
HIV because of fear oftransmission.
Like this can make them morecomfortable and this can make it
less of an issue in coupleswhere one person has HIV and the
other person doesn't.
So like there's so many andpleasure is so important.
And, you know, I think that weneed to change the paradigm a
little bit, but I, I think thatpart of it is something that
(41:42):
should be driven from the top interms of when it comes to
funding.
And when it comes to scientificjournals.
They should be making this moreof a priority.
So I was thrilled to see acouple of years ago, the
American journal of publichealth did kind of a special
section about pleasure and howthat was important to health.
(42:04):
And so, you know, they made thatsomething that they demonstrated
that that was something that'simportant issue and a priority
to them.
And I think when it comes tofunding, for example, a lot of
researchers go to the nationalinstitutes of health and it
would be great if they put out acall for research that focused
on enhancing sexual pleasure,instead of just like, oftentimes
(42:29):
it seems more about diseaseprevention.
And so it would be great ifthere was kind of a change in
thinking at the top, because Ithink that could also filter
down in terms of the sciencethat we actually do and the
research questions that westrive to answer.
Valerie Earnshaw (42:43):
Absolutely.
Oh, Sarah, you're such a greatexample of someone I think, who
feels really passionately aboutan area and someone who has
really focused on trying tounderstand a problem what's
happening with that problem.
And then identifying very doablesolutions.
(43:04):
I think that this is soimportant because there are so
many disparities, you know, whenit comes to PrEP and there's
just so much work that needs tobe done when only 18%, but
probably a lot fewer people whoare eligible for PrEP or who
could benefit from PrEP areactually accessing it.
(43:26):
It's a huge problem.
So just want to say, thank youfor all the excellent work
you're doing in this area.
Thank you for having me alongfor some of that work.
And in particular, thank youtoday 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 drawingattention to this issue and some
of my work and thank you for allyour contributions to the
research that we've donetogether.
I'm looking forward tocontinuing to collaborate on
that stuff.
Valerie Earnshaw (43:52):
You're so nice.
Cause you always refer to it asthe work we're doing together,
but I want every listener toknow that this is like Sarah
Calabrese, and like Valerie backin the wing.
So it's really generous thatyou've included me and I love
working on it with you andthinking about it.
So thank you.
Thank you.
Thanks to the Stigma and HealthInequities Lab at the University
(44:13):
of Delaware for their help atthe podcast, including Saray
Lopez, Molly Marine, JamesWallace, 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 clickingsubscribe.
Valerie Earnshaw (44:28):
Thanks to all of you for listening.
(45:04):
[inaudible].
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