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Rejecting Good Science on PrEP: Why Does it Happen?

, by Emily Land

This is too loud! Frustrated young man in formalwear holding heaLarge-scale trials, and recent evidence from the real-world PrEP program at Kaiser Permanente San Francisco, have shown that PrEP offers robust, effective protection against HIV. Yet some sections of the community still continue to question or reject it. Since Truvada-based PrEP’s FDA approval in 2012, the AIDS Healthcare Foundation, some AIDS activists, LGBT rights activists, physicians and others have criticized this HIV prevention strategy, which involves HIV-negative partners taking antiretrovirals as a barrier to infection.

The scientific community has addressed concerns about adherence, increasing STI rates, drug resistance and risk compensation and found PrEP is PrEP is 99% effective if the drug is taken as prescribed. So why is this effective, scientifically proven HIV-prevention method still subject to debate and dissent?

National Center for Science Education founding executive director Eugenie Scott, PhD, offers some insight. She has devoted her career to research and advocacy related to the creationism/evolution controversy—trying to understand why people reject scientific reasoning. She has applied theories about the rejection of scientific findings to anti-vaccination factions, climate change deniers, and creationists.

Eugenie Scott, PhD (Photo: NCSE)

Eugenie Scott, PhD (Photo: NCSE)

“The big idea here is that people are not solely logical and rational and unemotional about taking in new information and processing it and coming up with conclusions. Basically, people take in information and run it through filters,” Scott explained.

With science denial, Scott said, objections crop up around “pillars of denial” that exert a stronger influence on a person’s ultimate judgment or opinion than pure scientific fact.

Oftentimes, people reject scientific evidence out of “concern about whether the science really is solid.” Part of the issue, Scott said, was that some people lack understanding of scientific rigor. People who believe the risk of vaccines outweigh the benefit, or who reject the phenomenon of global warming, might not realize how long it takes, how difficult it is, and how much evidence is needed before scientists can reach a consensus about an event. When scientists reach a consensus, they’re sure about their findings but something is lost in translating that certainty to the public, she said.

“The iterative process takes a long time, and it is not easy. We find with things like evolution and climate change, while there’s a very strong consensus among scientists, the general public doesn’t seem to be impressed by this. In a Pew Foundation survey conducted in late 2014, 98% of scientists accept human evolution, but only 65% of the general public does. The same thing is true for climate change—87% of scientists think that global warming is due to human activity, but only 50% of the general public does.”

Scott said people also reject scientific evidence because of ideology or cultural values. For example, evangelical Christians might find their religion and the culture of their religious community at odds with a scientific understanding of evolution. Accepting evolution would be tantamount to rejecting their religious beliefs and their place of belonging in their faith community, she said.

Condoms, a cultural value for some

Using Scott’s explanation as a base, it may be that PrEP rejection comes from closely-held values around condom use—developed by gay men in response to the emotional, crisis-laden times of the eighties and nineties. Although PrEP use and condoms aren’t mutually exclusive—in fact, Truvada PrEP is approved by the FDA only in combination with other safer sex practices—often they’re pitted against each other.

Former University of Michigan law professor David Chambers, back in 1994, wrote “the answer to the epidemic, our ‘magic bullet’ is the condom, a thin layer of latex to shield us from infection and death.” At the height of the epidemic—and after—public health campaigns promoting condom use extended beyond information-only messaging to include value-laden appeals to morality and altruism so that always wearing a condom became the “right” thing to do, argued Chambers. The message gay men received, Chambers said, is that, “not wearing a condom is not simply unwise; it is wrong. Not wearing a condom violates obligations to other gay men, and in the views of some, obligations to a larger gay community.”

“Condoms have powerful meanings for gay men,” said Robert Grant, MD, MPH, of the Gladstone Institutes, the University of California at San Francisco and chief medical officer of San Francisco AIDS Foundation. “Many gay men started using condoms as part of the safe-sex movement that arose early in the AIDS epidemic. This safe-sex movement was an alternative to closing the bathhouses or giving up on sex at a time when friends and lovers were dying. Condoms were a way to be responsible and preserve some of the sexual dimensions of the gay-liberation movement that had blossomed in the 1970s. For some [people], condoms still mean being responsible during sex and respecting people who have died.”

There’s an emotional component too, says Eric Leue, the director of sexual health and advocacy at Kink.com. “Condoms were equated with ‘safe sex’ when in fact condoms are about risk reduction. This made it seem like condoms were the gold standard—were going to be 100% effective. But that’s never been realistic. So people got attached to that message, and now 30 years later with PrEP, and treatment as prevention, and other prevention options such as the bi-weekly HIV RNA testing used in the adult-film industry, it’s hard for people to wrap their heads around other forms of protection.”

Can strong opinions change?

In an article for the Huffington Post in August, Gay Dating Success founder Mike Alvear caused a stir by asking “Are PrEP-refusing gays the new anti-vaxxers?” Accused of anti-scientific views for choosing other methods of protection, he justified his decision and said that the decision to use PrEP depended on the person’s perceived risk, willingness to take other precautions and susceptibility to the drug’s side effects.

Though many comments on the article attack the author for being ignorant and miscalculating his risk, one Facebook commenter said: “The last thing we should be doing is replacing one “must” (always use condoms) with another (always take PrEP). Why do gay men feel so obliged to tell other gay men what to do all the time?”

Although many feel that PrEP is a personal decision that does not need to be defended, there may be instances when PrEP-takers feel compelled to combat its negative perceptions. For people that find fault with PrEP—out of fear of abandoning condoms or otherwise—does it make sense to try to change their views?

Scott says that—not surprisingly—it’s difficult to change someone’s minds once they’ve developed a strong opinion about a scientific finding or theory. In fact, research shows that giving additional scientific information to someone who has a strong opinion the other way actually leads them to “double-down” on their previously held conviction.

In a compelling study published in the Journal of Pediatrics, Brendan Nyhan, PhD and colleagues investigated whether four vaccine-promotion messages could change parents’ intent to vaccinate their children. Over 1,700 parents were provided with either: scientific evidence debunking the vaccine/autism link; disease risk associated with contracting measles, mumps or rubella; a narrative from a mother whose infant son contracted measles; or images of children who have contracted measles, mumps and rubella.

They found that none of the four interventions—which are all commonly-used public health strategies to promote vaccination—improved the likelihood that parents would vaccinate future children. In fact, parents that received information debunking the vaccine/autism link were even less likely to vaccinate future children after receiving the intervention. Among parents who joined the study holding the least favorable attitudes towards vaccines, their likelihood of giving the MMR vaccine to a child decreased from 70% to 45%.

This aligns with Scott’s observation from her time working with creationists. “It was clear to me that just shoveling more science at them wasn’t going to change their minds. They felt very strongly that evolution is false, and for the most religious, no amount of factual information or well-argued theory was going to talk them out of it,” she said.

An effective strategy, Scott said, was appealing to emotion and using influence from people holding a similar ideological position. “You really have to sit down and talk to people. To really understand what their objections are. That’s something that we tend not to do—we tend to demonize the opposition, and not have a respectful conversation.”

Leue said the key is not to convince people that PrEP is the best choice for them, but instead to help people see its benefit for those who choose it.

“I try to understand where people are coming from—and why they have that perspective. I listen, and say, ‘I get where you’re coming from, but now follow my line of thought. If you knew a person that is reluctant, or not able, to use condoms for whatever reason, would you agree that it’s important to tell them about other options they have to reduce their risk? Or would you think they just deserve to get whatever they get because they’re not doing what we told them to do?’ Most people would say, ‘I guess I would try to tell them about other options.’ And then you can say, ‘So we agree that options or choices are important.’”

Need additional information about PrEP? To learn more about PrEP, how it works, and how to get it, and to hear personal perspectives from PrEP users and medical providers, see the BETA “virtual library” on PrEP and check out prepfacts.org.


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