PrEP in Practice: a sociological study of HIV pre-exposure prophylaxis prescribing

HIV pre-exposure prophylaxis (PrEP) is a highly effective strategy for preventing new HIV infections. Since 2015, PrEP has been rapidly implemented with gay and bisexual men in Australia. While there is recognition of the importance of optimising the clinical delivery of PrEP, there has been scarce empirical research in Australia documenting how clinicians engage with prescribing PrEP, and minimal international social science research considering how PrEP has (re)shaped clinical practice. In this thesis I explore the role of clinicians in delivering PrEP in Australia. Drawing on the sociology of prescribing, I approach PrEP prescribing as a social practice, and attend to how clinicians anticipate and imagine patients, and how they think and feel about PrEP. This study draws on qualitative methodologies, including findings from semi-structured interviews conducted with clinicians who provide PrEP in New South Wales and Western Australia between 2019 and 2020, and with HIV expert stakeholders across Australia in 2017. Through empirical findings, I consider debates about which types of clinicians are best suited to prescribing PrEP and workforce challenges for providing PrEP in different clinical settings. I analyse clinician imaginaries of PrEP users and broader patient collectives, as well as clinicians’ views on providing PrEP to alleviate different types of ‘HIV anxiety’. I also examine prescribing as an affective clinical practice. I identify recommendations for supporting clinical workforces to improve the implementation of PrEP across Australian communities. This thesis demonstrates how PrEP has transformed HIV prevention for clinicians, requiring them to adapt to new ways of approaching HIV and sexual health. Clinicians develop expertise through routine opportunities to prescribe, and they develop imaginaries about patients and communities through consultations that shape their future interactions with patients. Conversely, a lack of patient demand makes it challenging for general practitioners to develop confidence and competence with PrEP prescribing. Providing PrEP involves the complexity of discussing sex and managing ideas about risk and responsibility, which are persistent challenges for both HIV-experienced and inexperienced clinicians. I argue for the value of sociological perspectives on clinical workforces to support and sustain effective HIV prevention