Assessing Osteopathic Medical Student Preparedness for Pre-Exposure Prophylaxis (PrEP) and HIV Prevention Care at Two U.S. Medical Schools

Assessing Osteopathic Medical Student Preparedness for Pre-Exposure Prophylaxis (PrEP) and HIV Prevention Care at Two U.S. Medical Schools | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing Osteopathic Medical Student Preparedness for Pre-Exposure Prophylaxis (PrEP) and HIV Prevention Care at Two U.S. Medical Schools Kyle J. Roe, Colton P. Boney, Zachary Montgomery, Rahul Garg, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8641255/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background : Pre-exposure prophylaxis (PrEP) is a highly effective strategy for HIV prevention, yet its uptake remains limited in part due to gaps in provider preparedness. Medical school represents a critical opportunity to prepare future physicians to deliver HIV preventive care; however, variability in curricular exposure and clinical training may result in uneven preparedness among graduating students. Methods : An anonymous, cross-sectional survey was administered to osteopathic medical students (years 1–4) at two U.S. medical schools. The survey assessed exposure to HIV/PrEP education, perceived clinical preparedness, and professional attitudes toward HIV and PrEP. Preparedness and attitudes were compared by institution, training stage (preclinical vs. clinical), and educational exposure using Fisher’s exact test. Results : A total of 122 students completed the survey (response rate 8.7%). 70% percent reported receiving preclinical HIV/PrEP education, yet only 16.8% reported any hands-on experience in HIV prevention or care. Students at one institution reported significantly greater preparedness across multiple domains, including overall HIV preventive care (65% vs. 26%, p < 0.0001), handling PrEP care, and taking a comprehensive sexual history. Clinical students reported greater preparedness for sexual history taking, whereas preclinical students reported greater preparedness to integrate PrEP discussions into routine visits. Receipt of HIV/PrEP education was associated with greater overall preparedness and stronger belief in PrEP effectiveness, but not with consistent preparedness across PrEP-specific clinical tasks. Conclusions : Medical students demonstrate strong awareness of HIV prevention but limited experiential training and variable preparedness for PrEP-specific care. Early curricular exposure improves perceived preparedness and confidence; however, inconsistent longitudinal reinforcement and lack of hands-on training highlight the need for standardized, competency-based, and experiential HIV/PrEP education across medical curricula to better prepare future physicians. Experiential learning Undergraduate medical education Clinical preparedness Medical student preparedness Pre-exposure prophylaxis (PrEP) HIV prevention education Osteopathic medical students 1. Background In 2019, the United States Department of Health and Human Services (HHS) introduced the Ending the HIV Epidemic in the United States (EHE) initiative, which aims to reduce new human immunodeficiency virus (HIV) diagnosis by 75% by 2025 and by 90% by 2030 ( 1 , 2 ), Meeting these goals relies on the healthcare workforce’s ability to provide and deliver effective prevention strategies. Pre-exposure prophylaxis (PrEP) is a highly effective method for preventing HIV when it is prescribed and taken as directed. However, provider-level barriers, such as limited knowledge, a lack of confidence, and insufficient clinical training, continue to restrict the broader use of PrEP. Physicians play a key role in meeting the objectives of EHE. Studies have shown that many medical schools do not provide adequate training in HIV prevention and PrEP, which can limit progress. A 2021 study of 71 medical schools revealed that 38% of them offered PrEP education, with didactic lectures being the most common instructional method ( 3 ). None of the programs reported using simulated or standardized patients as an instructional method, and only 5.6% reported direct patient experiences as a teaching method ( 3 ). Other research has shown the benefits of including standardized patients or simulated clinical encounters as part of the instruction for sexual health ( 4 ). This form of teaching allows students to practice their skills in a low-stakes environment and allows for constructive feedback on how to improve. By not including simulated training or standardized patients in the learning process trainees are left underprepared to discuss sexual health, identify patients who may benefit from PreP, and manage PrEP in clinical practice. As a result, gaps in provider preparedness remain a major barrier to PrEP uptake. This lack of preparedness is evident in primary care, where most patients at risk for HIV have access to routine care. Compared with HIV specialists, primary care providers are less aware of PrEP and prescribe it less often ( 5 ). This gap is a significant barrier in rural and underserved areas, where patients rely on generalist physicians and may not have access to HIV specialists. Additional barriers to PrEP delivery include stigma, discomfort with sexual health discussions, and limited experience caring for sexual and gender minority patients ( 2 , 3 , 5 – 8 ). These issues can be especially noted among rural and black men who have sex with men (MSM). A study investigating rural MSM in Oklahoma noted that providers’ lack of knowledge about PrEP affects patients’ experience receiving PrEP care ( 9 ). Going beyond knowledge of PrEP, the patient–provider relationship is often strained by cultural disconnects and medical mistrust, which are notable barriers to PrEP uptake among rural and black MSM ( 7 , 9 , 10 ). In rural contexts, limited provider knowledge often forces patients to educate their own clinicians. This disclosure of same-sex behavior can shift relationships from “friendly” to “strictly business” or “emotionally cold”( 9 ). For black MSM, this mistrust is often rooted in historically unethical experiments and insensitive care, leading to reluctance to discuss sexual health or engage with the healthcare system at all ( 7 , 10 ). Ultimately, the fear that clinical staff may judge or even disclose private information to friends and family in small communities prevents vulnerable populations from accessing effective HIV prevention ( 9 , 10 ). Regional differences in HIV rates make it important to examine how medical training varies by location. The southern United States has the highest HIV incidence in the country, with rates more than twice those in the Midwest and Northeast ( 11 , 12 ). Additionally, the southern United States also has the lowest PrEP-to-Need Ratio ( 13 ). These disparities raise important questions about whether medical students in high-burden areas receive the training needed to provide effective HIV prevention. Most studies on PrEP instruction in U.S. medical schools have focused on curriculum content and teaching methods rather than on students’ preparedness or attitudes toward PrEP ( 3 , 14 ). Few studies have specifically examined the southern United States, even though this region is central to national HIV prevention efforts. Research in the South has focused mainly on patient-level barriers such as stigma and mistrust rather than how ready future physicians are to provide care ( 15 ). Studies in other health professions have shown that stigma and a lack of cultural competency training can negatively affect patient outcomes, highlighting the need to improve both clinical skills and attitudes in medical education ( 16 , 17 ). Our study examines how prepared U.S. osteopathic medical students are to provide HIV prevention and PrEP care, with a focus on differences between the South and the Midwest. By assessing students’ educational experiences, clinical preparedness, and attitudes toward HIV and PrEP, this study aims to identify strengths and gaps in current training. Understanding where preparedness is lacking and how it varies by region and training stage can guide targeted curriculum changes and support a more consistent, competency-based approach to HIV prevention education, ensuring that future physicians are ready to help end the HIV epidemic. 2. Methods This study used a cross-sectional survey design in accordance with STROBE reporting guidelines for observational studies. 2.1. Participants An online survey was distributed between August and November 2024 to two osteopathic medical schools via Qualtrics® (Provo, UT). The survey was sent to all enrolled students in years one through four of their medical training at a medical school in Alabama (South) and Indiana (Midwest), with an estimated 800 students in the South and 600 in the Midwest ( 18 – 25 ). The participants voluntarily agreed to complete the anonymous survey and were not offered any compensation. 2.2. Measure Development Our survey instrument was developed for this study and was informed by previous studies of medical students regarding PrEP ( 14 ). The survey was reviewed by a pharmacology instructor at the southern institution, who primarily teaches PrEP and HIV treatment in the medical school’s curriculum. The complete survey is available in Additional file 1. Items related to PrEP education asked whether PrEP and HIV risk factors had been taught at any time during their medical school training and whether they had any hands-on training or experience with HIV prevention and care during their time in medical school. Attitudes about PrEP and caring for HIV-positive patients were also assessed. Additional questions included how prepared those who had received education on PrEP and/or HIV risk factors were to handle various aspects of PrEP care via a 5-point Likert scale (1 = not prepared, 5 = extremely prepared). The survey instrument collected data on gender identity, race/ethnicity, year of training, and desired medical specialty for residency training. Desired medical specialties were grouped into “primary care” and “nonprimary care” on the basis of what each medical school classified as primary care in their residency placement reports ( 26 , 27 ). Specialties categorized as primary care vs. nonprimary care are available in Additional file 2. 2.3. Statistical analysis Descriptive statistics were used to summarize the sample. Respondents from the two medical schools were assigned to the Midwest or the South based on their U.S. region. The year of training was collapsed into preclinical (years 1 & 2) and clinical (years 3 & 4). Residency specialty choice was grouped into primary care and nonprimary care (Additional file 2). Associations among categorical variables (e.g., regional location, training level, and perceived preparedness) were assessed via contingency tables. Fisher’s exact test was used for all inferential comparisons instead of the Pearson chi-square test to ensure statistical validity, given the limited sample size. All the statistical tests were two-tailed, and a p value < 0.05 was considered statistically significant. All the statistics were computed via SAS version 9.4 (SAS Institute Inc., Cary, NC). 3. Results 3.1. Demographics and Education Exposure A total of 122 respondents completed the survey, yielding an estimated response rate of 8.7% (Table 1 ). Of these, 77 (63%) were from the southern institution, and 45 (37%) were from the midwestern institution. More than half of the respondents (n = 67, 55%) indicated plans to pursue a non–primary care specialty. All four years of medical training were represented among the respondents. Seventy percent of the respondents reported receiving education on HIV and PrEP during their preclinical curriculum. Among those who had not yet received PrEP and/or HIV education, 72% were still aware of PrEP as an HIV prevention method. Among the respondents who had received HIV/PrEP education, 66% agreed or strongly agreed that the education was adequate. Only 17% of the respondents reported any hands-on training or clinical experience related to HIV prevention or care during medical school. However, 77% indicated that hands-on experience in HIV prevention and care is very or extremely important for medical students. Table 1 Demographics of the respondents Characteristics Total Southern Midwest Gender Identity Male 45 34 11 Female 76 42 34 Race Asian 15 12 3 Black 3 1 2 White 100 61 39 Prefer not to say 7 5 2 Hispanic/Latino Yes 11 9 2 No 106 63 43 Year in Medical School Year 1 26 15 11 Year 2 40 26 14 Year 3 28 17 11 Year 4 28 19 9 Desired Specialty Primary care 55 34 21 Nonprimary care 67 43 24 3.2. Regional Preparedness Preparedness outcomes differed between respondents from southern and midwestern institutions (Table 2 ). Students in the south were more likely to report feeling moderately to extremely prepared to provide HIV preventative care overall than were those in the midwest (65% vs. 26%, p < 0.0001). Southern students also reported greater preparedness to handle PrEP care (49% vs. 14%, p = 0.002), take a comprehensive sexual history (86% vs. 60%, p = 0.006), and discuss HIV prevention strategies other than PrEP (80% vs. 52%, p = 0.005). The difference in preparedness to integrate PrEP discussions into routine healthcare visits between regions was not statistically significant (43% vs. 21%, p = 0.059). No statistically significant regional differences were observed in attitudes or beliefs related to HIV and PrEP (Table 3 ). The respondents in the south and midwest did not differ in their perceived importance of hands-on experience, belief in PrEP effectiveness, comfort in caring for patients living with HIV, or willingness to work in communities with high HIV prevalence. Table 2 Clinical preparedness for HIV prevention and PrEP care by region and training stage Survey Item South (%) Midwest (%) p value Preclinical (%) Clinical (%) p value Handle PrEP care 49 14 0.0019 * 44 32 0.26 Take sexual history 86 60 0.0060 * 63 87 0.018 * Discuss other prevention 80 52 0.0053 * 74 68 0.63 Integrate PrEP discussions 43 21 0.059 54 23 0.0051 * Overall preparedness 65 26 < 0.0001 * 48 55 0.46 *Statistically significant at p < 0.05 using Fisher’s exact test. Percentage of students who felt “Moderately to Extremely Prepared.” Table 3 Attitudes and Beliefs Regarding HIV and PrEP by Region and Stage of Training Survey Item South (%) Midwest (%) p value Preclinical (%) Clinical (%) p value Importance of hands-on experience (% very to extremely important) 76 80 0.66 78 76 0.83 Belief PrEP is effective (% strongly agree) 77 61 0.12 66 77 0.29 Comfort caring for HIV+ (% some to extreme comfort) 78 62 0.21 74 69 0.83 Work in high HIV prevalence area (% Yes) 79 67 0.38 79 69 0.37 *Statistically significant at p < 0.05 using Fisher’s exact test. 3.3. Differences by training level Preparedness was also compared by training stage, with preclinical (years 1–2) and clinical (years 3–4) students (Table 2 ). Clinical students were more likely to report feeling prepared to take a comprehensive sexual history (87% vs. 63%, p = 0.018). In contrast, preclinical students more often reported preparedness to integrate PrEP discussions into routine healthcare visits (54% vs. 23%, p = 0.005). No statistically significant differences by training level were observed for preparedness to handle PrEP care, discussing alternative HIV prevention strategies, or providing HIV preventative care overall. There were no statistically significant differences between preclinical and clinical students in attitudes or beliefs related to HIV and PrEP (Table 3 ), including the perceived importance of hands-on experience, belief in PrEP effectiveness, comfort in caring for patients living with HIV, or willingness to work in high-HIV-prevalence communities. 3.4. Impact of Education Exposure Compared with those without such education, those who received preclinical HIV/PrEP education were more likely to report feeling moderately to extremely prepared to provide HIV preventative care overall (65% vs. 17%, p < 0.0001) (Table 4 ). They were also more likely to report preparedness to take a comprehensive sexual history (84% vs. 43%, p = 0.003). No statistically significant differences were observed between these groups for preparedness to handle PrEP care, discussing other HIV prevention strategies, or integrating PrEP discussions into routine healthcare visits. With respect to attitudes and beliefs (Table 4 ), respondents who had received HIV/PrEP education were more likely to strongly agree that PrEP is an effective method of HIV prevention (77% vs. 52%, p = 0.025). No statistically significant differences were observed for the perceived importance of hands-on experience, comfort caring for patients living with HIV, or willingness to work in high-HIV-prevalence areas. Among respondents who had received HIV/PrEP education, the perceived adequacy of education was associated with preparedness outcomes (Table 5). Higher perceived adequacy corresponded to greater reported preparedness to handle PrEP care (p = 0.0004), integrate PrEP discussions into routine visits (p = 0.002), and provide HIV preventative care overall (p < 0.0001). Preparedness to take a comprehensive sexual history and to discuss other prevention strategies did not differ significantly by perceived education adequacy. The associations between perceived education adequacy and attitudes or comfort levels are shown in Table 5. The respondents who perceived their education as adequate were more likely to report being comfortable with patients living with HIV (p = 0.022). No statistically significant associations were observed for perceived importance of hands-on experience, belief in PrEP effectiveness, or willingness to work in high-HIV-prevalence communities. Table 4 Association between Preclinical HIV/PrEP Education and Student Preparedness and Attitudes Survey Item Received Education (%) No Education (%) p value Handle PrEP care 40 23 0.35 Take sexual history 84 43 0.003 * Discuss other prevention 75 50 0.11 Integrate PrEP discussions 37 29 0.76 Overall preparedness 65 17 < 0.0001 * Importance of hands-on experience (% very to extremely important) 76 81 0.64 Belief PrEP is effective (% strongly agree) 77 52 0.025 * Comfort caring for HIV+ (% some to extreme comfort) 74 66 0.55 Work in high HIV prevalence area (% Yes) 74 75 0.56 *Statistically significant at p < 0.05 using Fisher’s exact test. Percent of students who felt “Moderately to Extremely Prepared” Table 5: Association between the Perceived Adequacy of Education and the Clinical Preparedness of Students who Felt Moderately to Extremely Prepared Survey Item Education Inadequate (Disagree) (%) Education Neutral (%) Education Adequate (Agree) (%) p value Handle PrEP care 0 25 49 0.0004 * Take sexual history 89 50 79 0.078 Discuss other prevention 59 50 79 0.087 Integrate PrEP discussions 6 13 47 0.002 * Overall Preparedness 25 33 80 < 0.0001 * Importance of hands-on experience (% Very to Extremely Important) 70 80 79 0.74 Belief PrEP is effective (% Strongly Agree) 63 63 80 0.21 Comfort caring for HIV+ patients (% Some to Extreme Comfort) 53 78 85 0.022 * Work in high HIV prevalence area (% Yes) 84 78 75 0.76 *Statistically significant at p < 0.05 using Fisher’s exact test. 4. Discussion This study assessed osteopathic medical students' preparedness to provide HIV prevention and PrEP care, with attention to regional differences, training stages, and educational exposure. While differences were observed between students at the two participating programs, these findings are best interpreted in the context of curricular structure and educational emphasis rather than geographic region alone. Across both schools, students demonstrated strong interest in HIV prevention but limited hands-on experience. Progression through medical school improved some general clinical skills but did not lead to increased preparedness for PrEP-specific care. Exposure to HIV and PrEP education was associated with greater overall preparedness and greater belief in PrEP effectiveness but did not consistently improve confidence in performing PrEP-related clinical tasks. These findings indicate a need for curricula to include more hands-on training and standardized educational benchmarks to ensure that all medical students achieve a baseline level of competence in PrEP and sexual health care. 4.1. Institutional Differences in Preparedness Students at the southern institution reported greater preparedness across several PrEP-related clinical domains than did those at the midwestern institution. However, given that only one medical school from each region was included, these differences should not be interpreted as regional effects. Instead, they are more likely to reflect differences in institutional curricula, instructional emphasis, and the reinforcement of HIV prevention concepts. The southern institution’s location in a high-HIV-burden area may contribute to greater curricular prioritization of HIV prevention, offering a model that could be adapted by other medical schools regardless of geographic location. 4.2. The experiential gap Few students at either institution reported receiving hands-on training or clinical experience with HIV prevention or PrEP care. Most students identified hands-on experience as important, highlighting a gap between current instruction methods and students' educational needs. While didactic instruction provides foundational knowledge, experiential learning is necessary to develop the communication, counseling, and clinical decision-making skills required for effective PrEP and overall sexual health care. The limited clinical exposure reported by students suggests that opportunities to apply PrEP-related knowledge during rotations are inconsistent or infrequent. Without structured clinical experiences or supervised practices, students may graduate from medical schools with knowledge of PrEP but lack confidence in initiating discussions, assessing patient eligibility, or managing follow-up care. Addressing this gap will require integrating experiential learning opportunities, including standardized patient encounters, simulation exercises, and required clinical objectives, into core clinical rotations. Studies have shown that hands-on training with standardized patients in observed structured clinical examinations (OSCEs) or other simulation-based clinical encounters improves sexual history-taking and HIV-related care ( 4 ). These findings suggest that didactic exposure alone, without the intentional integration of experiential learning into the curriculum, is insufficient to ensure competence in PrEP delivery, regardless of training location. 4.3. Preparedness by training stage Differences by training stage revealed a mixed pattern. Clinical students reported greater preparedness to have a comprehensive sexual history. This is to be expected with increased patient contact and repetition of general clinical skills during rotations. In contrast, preclinical students reported greater preparedness to integrate PrEP discussions into routine healthcare visits. This difference may reflect the perspectives of early versus advanced trainees. Preclinical students, with recent classroom-based exposure to PrEP, may find discussions of PrEP more straightforward. Clinical students who face time constraints and more complex patient interactions may find incorporating PrEP conversations into routine care more challenging. Overall preparedness and ability to provide PrEP care did not differ significantly by training level. One reason is that PrEP-specific skills are not reinforced as students progress through medical school. Research has shown that one year after receiving basic science knowledge, two-thirds to three-fourths of that knowledge remains. However, this percentage decreases to less than 50% at two years post-receiving ( 28 ). This may explain why preclinical students feel better prepared to integrate PrEP discussions, as they are most familiar with the patients who would benefit most from this prevention strategy. Regardless, increased exposure to information regarding HIV prevention and PrEP has been shown to improve physician willingness to prescribe ( 29 ). As physicians specialize, the education and training they receive after medical school in HIV prevention are variable. Medical school preclinical training provides the opportunity for a common educational framework for future physicians. It should attempt to target public health information, such as HIV and sexually transmitted infection (STI) prevention and PrEP. Additionally, as students encounter patients for the first time, their level of confidence in discussing sexual health topics diminishes. While students may feel confident in discussing PrEP in theory, they lose confidence when it is time to put their learning into clinical practice. This lack of confidence can also extend into residency training ( 30 ). Together, these findings suggest that early curricular exposure may increase confidence in PrEP-related concepts. However, without longitudinal reinforcement and applied practice, this confidence may diminish as students transition into more complex clinical environments. 4.4. Impact of Educational Exposure Exposure to preclinical HIV/PrEP education was associated with greater overall preparedness to provide HIV preventative care and greater confidence in having a comprehensive sexual history. Students who had received formal education were also more likely to strongly endorse the effectiveness of PrEP. These findings indicate that existing curricula successfully convey the conceptual importance and scientific basis of HIV prevention. However, educational exposure alone did not result in significantly greater preparedness to manage PrEP care or to include PrEP discussions in routine visits. Even students who considered their education adequate showed differences in preparedness across clinical tasks. These findings suggest that preclinical instruction provides a foundation, but additional applied training is needed to develop practical competence in PrEP delivery. To assess this ability, methods such as objective structured clinical examinations (OSCEs) and simulated clinical encounters could be used. These techniques would allow educators to evaluate and provide feedback on students' practical skills in real-world settings while giving students opportunities to practice these skills in a low-stakes environment. 4.5. Implications for Medical Education The findings of this study highlight the importance of early, structured, longitudinal HIV and PrEP education within medical school curricula. Differences in preparedness between institutions appear to be driven more by curricular emphasis than by student attitudes or motivation. Medical schools that prioritize HIV prevention—particularly through early academic instruction paired with experiential learning—may better prepare students to engage in PrEP discussions, manage preventive care, and address sexual health confidently in clinical practice. Curricula that include experiential learning and repeated clinical application, in addition to didactic instruction, may help students apply knowledge in practice. The inclusion of PrEP-related objectives in core clinical rotations and the use of structured teaching methods may better prepare students to provide HIV prevention care in various practice settings. 5. Limitations This study has several limitations. Although the response rate was low, it is comparable to other voluntary survey-based studies of medical students and may reflect survey fatigue in this population. The use of a convenience sample from two medical schools limits generalizability, and the low response rate raises the possibility of response bias. Preparedness was self-reported and may not reflect objective clinical competence. Additionally, causal inferences cannot be drawn due to the cross-sectional design. Despite these limitations, the study provides insight into how educational exposure, training stage, and regional context relate to medical student preparedness for HIV prevention and PrEP care. These findings highlight areas for improvement in medical education and suggest a need for more consistent HIV prevention training across diverse educational settings. Addressing similar educational gaps could help institutions better prepare students for the challenges of HIV prevention and PrEP care. Additionally, because only one institution per region was included, the observed differences should be interpreted as institutional rather than regional, and future studies should include multiple schools per region to better assess geographic trends. 6. Conclusion This study identifies both strengths and gaps in medical student preparedness for HIV prevention and PrEP care. Students demonstrate strong interest and positive attitudes toward caring for people affected by HIV, but there are ongoing deficiencies in hands-on training and variability in preparedness. Addressing these gaps with standardized, experiential, and ongoing educational strategies may better prepare future physicians to support efforts to reduce the impact of the HIV epidemic. Abbreviations EHE: Ending the HIV Epidemic in the United States HHS: United States Department of Health and Human Services HIV: Human immunodeficiency virus MSM: Men who have sex with men OSCE: Objective structured clinical examination PrEP: Pre-exposure prophylaxis STI: Sexually transmitted infection Declarations Ethics approval and consent to participate: The Institutional Review Board at the Alabama College of Osteopathic Medicine reviewed the protocol and determined that the study was exempt from full review (24-07-09-001-ACOM). The study was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all participants, and consent was implied by voluntary completion and submission of the anonymous survey. Consent for publication: Not applicable. Competing interests: The authors declare that they have no competing interests. Funding: Not applicable. Author Contribution KR and CB developed the survey. 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Beebe S, Payne N, Posid T, Diab D, Horning P, Scimeca A, et al. The Lack of Sexual Health Education in Medical Training Leaves Students and Residents Feeling Unprepared. J Sex Med. 2021;18(12):1998-2004. Additional Declarations No competing interests reported. Supplementary Files Additionalfile2.docx Additionalfile1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 17 Feb, 2026 Reviewers invited by journal 17 Feb, 2026 Editor assigned by journal 16 Feb, 2026 Editor invited by journal 27 Jan, 2026 Submission checks completed at journal 24 Jan, 2026 First submitted to journal 24 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8641255","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":594073892,"identity":"a124fb41-800b-4886-b402-05b021c05939","order_by":0,"name":"Kyle J. Roe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvklEQVRIiWNgGAWjYHACZuYfBhI8/FAeYwNRWhgqLOQkG0jTcqbC2OAAsVrM25sPGxe2SSRuPn744aMbDDayGw4Q0CJz5lhy8kyglm1n0oyNcxjSjAlqkZDIMT7AC9JyIIdNOofhcCIRWvI/g7Vs7n8D0vKfGC05zMk8ZySMDSTAthwgQgvPMWPDGRUSchI3ngH9YpBsPJOgFvbmxxIfDOp4+PuTHz7OqbCT7SOkBQ0YkKZ8FIyCUTAKRgEOAABuTUB4HvTxNgAAAABJRU5ErkJggg==","orcid":"","institution":"Alabama College of Osteopathic Medicine","correspondingAuthor":true,"prefix":"","firstName":"Kyle","middleName":"J.","lastName":"Roe","suffix":""},{"id":594073894,"identity":"93c02677-6ad6-4084-83e9-227f0a8cc8b0","order_by":1,"name":"Colton P. Boney","email":"","orcid":"","institution":"Legacy Emanuel Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Colton","middleName":"P.","lastName":"Boney","suffix":""},{"id":594073895,"identity":"0cff799f-3a85-4529-a848-b4b88023f8fc","order_by":2,"name":"Zachary Montgomery","email":"","orcid":"","institution":"Marian University Tom and Julie Wood School of Osteopathic Medicine","correspondingAuthor":false,"prefix":"","firstName":"Zachary","middleName":"","lastName":"Montgomery","suffix":""},{"id":594073896,"identity":"1c45da1a-b06f-40cc-9cfd-e855cb491092","order_by":3,"name":"Rahul Garg","email":"","orcid":"","institution":"Alabama College of Osteopathic Medicine","correspondingAuthor":false,"prefix":"","firstName":"Rahul","middleName":"","lastName":"Garg","suffix":""},{"id":594073898,"identity":"140ebe4c-546f-44bb-a40b-d032c9e7289d","order_by":4,"name":"Robert W. Parker, III","email":"","orcid":"","institution":"Alabama College of Osteopathic Medicine","correspondingAuthor":false,"prefix":"","firstName":"III","middleName":"Robert W.","lastName":"Parker","suffix":""}],"badges":[],"createdAt":"2026-01-19 16:07:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8641255/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8641255/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103504119,"identity":"9f6fc8c0-a163-49ac-b159-15be048c1bb0","added_by":"auto","created_at":"2026-02-26 13:17:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1015120,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8641255/v1/a3cbbc28-a382-4a52-9d92-5cd7b399acde.pdf"},{"id":103084988,"identity":"0469f67f-6b43-4ece-81e2-1d50bba9550c","added_by":"auto","created_at":"2026-02-20 15:35:30","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":15928,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8641255/v1/03da0971ea0ce481040a80be.docx"},{"id":103084989,"identity":"33e397d1-9456-4c55-a54f-090c40007306","added_by":"auto","created_at":"2026-02-20 15:35:30","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":38443,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8641255/v1/320578101a96c42d6c76e20c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing Osteopathic Medical Student Preparedness for Pre-Exposure Prophylaxis (PrEP) and HIV Prevention Care at Two U.S. Medical Schools","fulltext":[{"header":"1. Background","content":"\u003cp\u003eIn 2019, the United States Department of Health and Human Services (HHS) introduced the \u003cem\u003eEnding the HIV Epidemic in the United States\u003c/em\u003e (EHE) initiative, which aims to reduce new human immunodeficiency virus (HIV) diagnosis by 75% by 2025 and by 90% by 2030 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), Meeting these goals relies on the healthcare workforce\u0026rsquo;s ability to provide and deliver effective prevention strategies. Pre-exposure prophylaxis (PrEP) is a highly effective method for preventing HIV when it is prescribed and taken as directed. However, provider-level barriers, such as limited knowledge, a lack of confidence, and insufficient clinical training, continue to restrict the broader use of PrEP.\u003c/p\u003e \u003cp\u003ePhysicians play a key role in meeting the objectives of EHE. Studies have shown that many medical schools do not provide adequate training in HIV prevention and PrEP, which can limit progress. A 2021 study of 71 medical schools revealed that 38% of them offered PrEP education, with didactic lectures being the most common instructional method (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). None of the programs reported using simulated or standardized patients as an instructional method, and only 5.6% reported direct patient experiences as a teaching method (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Other research has shown the benefits of including standardized patients or simulated clinical encounters as part of the instruction for sexual health (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This form of teaching allows students to practice their skills in a low-stakes environment and allows for constructive feedback on how to improve. By not including simulated training or standardized patients in the learning process trainees are left underprepared to discuss sexual health, identify patients who may benefit from PreP, and manage PrEP in clinical practice. As a result, gaps in provider preparedness remain a major barrier to PrEP uptake.\u003c/p\u003e \u003cp\u003eThis lack of preparedness is evident in primary care, where most patients at risk for HIV have access to routine care. Compared with HIV specialists, primary care providers are less aware of PrEP and prescribe it less often (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This gap is a significant barrier in rural and underserved areas, where patients rely on generalist physicians and may not have access to HIV specialists. Additional barriers to PrEP delivery include stigma, discomfort with sexual health discussions, and limited experience caring for sexual and gender minority patients (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). These issues can be especially noted among rural and black men who have sex with men (MSM). A study investigating rural MSM in Oklahoma noted that providers\u0026rsquo; lack of knowledge about PrEP affects patients\u0026rsquo; experience receiving PrEP care (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGoing beyond knowledge of PrEP, the patient\u0026ndash;provider relationship is often strained by cultural disconnects and medical mistrust, which are notable barriers to PrEP uptake among rural and black MSM (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In rural contexts, limited provider knowledge often forces patients to educate their own clinicians. This disclosure of same-sex behavior can shift relationships from \u0026ldquo;friendly\u0026rdquo; to \u0026ldquo;strictly business\u0026rdquo; or \u0026ldquo;emotionally cold\u0026rdquo;(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). For black MSM, this mistrust is often rooted in historically unethical experiments and insensitive care, leading to reluctance to discuss sexual health or engage with the healthcare system at all (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Ultimately, the fear that clinical staff may judge or even disclose private information to friends and family in small communities prevents vulnerable populations from accessing effective HIV prevention (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegional differences in HIV rates make it important to examine how medical training varies by location. The southern United States has the highest HIV incidence in the country, with rates more than twice those in the Midwest and Northeast (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Additionally, the southern United States also has the lowest PrEP-to-Need Ratio (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). These disparities raise important questions about whether medical students in high-burden areas receive the training needed to provide effective HIV prevention.\u003c/p\u003e \u003cp\u003eMost studies on PrEP instruction in U.S. medical schools have focused on curriculum content and teaching methods rather than on students\u0026rsquo; preparedness or attitudes toward PrEP (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Few studies have specifically examined the southern United States, even though this region is central to national HIV prevention efforts. Research in the South has focused mainly on patient-level barriers such as stigma and mistrust rather than how ready future physicians are to provide care (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Studies in other health professions have shown that stigma and a lack of cultural competency training can negatively affect patient outcomes, highlighting the need to improve both clinical skills and attitudes in medical education (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study examines how prepared U.S. osteopathic medical students are to provide HIV prevention and PrEP care, with a focus on differences between the South and the Midwest. By assessing students\u0026rsquo; educational experiences, clinical preparedness, and attitudes toward HIV and PrEP, this study aims to identify strengths and gaps in current training. Understanding where preparedness is lacking and how it varies by region and training stage can guide targeted curriculum changes and support a more consistent, competency-based approach to HIV prevention education, ensuring that future physicians are ready to help end the HIV epidemic.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e This study used a cross-sectional survey design in accordance with STROBE reporting guidelines for observational studies.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Participants\u003c/h2\u003e \u003cp\u003eAn online survey was distributed between August and November 2024 to two osteopathic medical schools via Qualtrics\u0026reg; (Provo, UT). The survey was sent to all enrolled students in years one through four of their medical training at a medical school in Alabama (South) and Indiana (Midwest), with an estimated 800 students in the South and 600 in the Midwest (\u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The participants voluntarily agreed to complete the anonymous survey and were not offered any compensation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Measure Development\u003c/h2\u003e \u003cp\u003eOur survey instrument was developed for this study and was informed by previous studies of medical students regarding PrEP (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The survey was reviewed by a pharmacology instructor at the southern institution, who primarily teaches PrEP and HIV treatment in the medical school\u0026rsquo;s curriculum. The complete survey is available in Additional file 1.\u003c/p\u003e \u003cp\u003eItems related to PrEP education asked whether PrEP and HIV risk factors had been taught at any time during their medical school training and whether they had any hands-on training or experience with HIV prevention and care during their time in medical school. Attitudes about PrEP and caring for HIV-positive patients were also assessed. Additional questions included how prepared those who had received education on PrEP and/or HIV risk factors were to handle various aspects of PrEP care via a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;not prepared, 5\u0026thinsp;=\u0026thinsp;extremely prepared). The survey instrument collected data on gender identity, race/ethnicity, year of training, and desired medical specialty for residency training. Desired medical specialties were grouped into \u0026ldquo;primary care\u0026rdquo; and \u0026ldquo;nonprimary care\u0026rdquo; on the basis of what each medical school classified as primary care in their residency placement reports (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Specialties categorized as primary care vs. nonprimary care are available in Additional file 2.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Statistical analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to summarize the sample. Respondents from the two medical schools were assigned to the Midwest or the South based on their U.S. region. The year of training was collapsed into preclinical (years 1 \u0026amp; 2) and clinical (years 3 \u0026amp; 4). Residency specialty choice was grouped into primary care and nonprimary care (Additional file 2). Associations among categorical variables (e.g., regional location, training level, and perceived preparedness) were assessed via contingency tables. Fisher\u0026rsquo;s exact test was used for all inferential comparisons instead of the Pearson chi-square test to ensure statistical validity, given the limited sample size. All the statistical tests were two-tailed, and a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. All the statistics were computed via SAS version 9.4 (SAS Institute Inc., Cary, NC).\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Demographics and Education Exposure\u003c/h2\u003e \u003cp\u003eA total of 122 respondents completed the survey, yielding an estimated response rate of 8.7% (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of these, 77 (63%) were from the southern institution, and 45 (37%) were from the midwestern institution. More than half of the respondents (n\u0026thinsp;=\u0026thinsp;67, 55%) indicated plans to pursue a non\u0026ndash;primary care specialty. All four years of medical training were represented among the respondents.\u003c/p\u003e \u003cp\u003eSeventy percent of the respondents reported receiving education on HIV and PrEP during their preclinical curriculum. Among those who had not yet received PrEP and/or HIV education, 72% were still aware of PrEP as an HIV prevention method. Among the respondents who had received HIV/PrEP education, 66% agreed or strongly agreed that the education was adequate.\u003c/p\u003e \u003cp\u003eOnly 17% of the respondents reported any hands-on training or clinical experience related to HIV prevention or care during medical school. However, 77% indicated that hands-on experience in HIV prevention and care is very or extremely important for medical students.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics of the respondents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCharacteristics\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSouthern\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eMidwest\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender Identity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrefer not to say\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHispanic/Latino\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYear in Medical School\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDesired Specialty\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonprimary care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Regional Preparedness\u003c/h2\u003e \u003cp\u003ePreparedness outcomes differed between respondents from southern and midwestern institutions (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Students in the south were more likely to report feeling moderately to extremely prepared to provide HIV preventative care overall than were those in the midwest (65% vs. 26%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Southern students also reported greater preparedness to handle PrEP care (49% vs. 14%, p\u0026thinsp;=\u0026thinsp;0.002), take a comprehensive sexual history (86% vs. 60%, p\u0026thinsp;=\u0026thinsp;0.006), and discuss HIV prevention strategies other than PrEP (80% vs. 52%, p\u0026thinsp;=\u0026thinsp;0.005).\u003c/p\u003e \u003cp\u003eThe difference in preparedness to integrate PrEP discussions into routine healthcare visits between regions was not statistically significant (43% vs. 21%, p\u0026thinsp;=\u0026thinsp;0.059).\u003c/p\u003e \u003cp\u003eNo statistically significant regional differences were observed in attitudes or beliefs related to HIV and PrEP (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The respondents in the south and midwest did not differ in their perceived importance of hands-on experience, belief in PrEP effectiveness, comfort in caring for patients living with HIV, or willingness to work in communities with high HIV prevalence.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical preparedness for HIV prevention and PrEP care by region and training stage\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSurvey Item\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSouth (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eMidwest (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ePreclinical (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eClinical (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHandle PrEP care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.0019\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTake sexual history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.0060\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscuss other prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.0053\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntegrate PrEP discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.0051\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall preparedness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Statistically significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 using Fisher\u0026rsquo;s exact test.\u003c/p\u003e \u003cp\u003ePercentage of students who felt \u0026ldquo;Moderately to Extremely Prepared.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAttitudes and Beliefs Regarding HIV and PrEP by Region and Stage of Training\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSurvey Item\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSouth (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eMidwest (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ePreclinical (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eClinical (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImportance of hands-on experience\u003c/p\u003e \u003cp\u003e(% very to extremely important)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelief PrEP is effective\u003c/p\u003e \u003cp\u003e(% strongly agree)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComfort caring for HIV+\u003c/p\u003e \u003cp\u003e(% some to extreme comfort)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork in high HIV prevalence area\u003c/p\u003e \u003cp\u003e(% Yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Statistically significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 using Fisher\u0026rsquo;s exact test.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Differences by training level\u003c/h2\u003e \u003cp\u003ePreparedness was also compared by training stage, with preclinical (years 1\u0026ndash;2) and clinical (years 3\u0026ndash;4) students (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Clinical students were more likely to report feeling prepared to take a comprehensive sexual history (87% vs. 63%, p\u0026thinsp;=\u0026thinsp;0.018). In contrast, preclinical students more often reported preparedness to integrate PrEP discussions into routine healthcare visits (54% vs. 23%, p\u0026thinsp;=\u0026thinsp;0.005).\u003c/p\u003e \u003cp\u003eNo statistically significant differences by training level were observed for preparedness to handle PrEP care, discussing alternative HIV prevention strategies, or providing HIV preventative care overall.\u003c/p\u003e \u003cp\u003eThere were no statistically significant differences between preclinical and clinical students in attitudes or beliefs related to HIV and PrEP (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), including the perceived importance of hands-on experience, belief in PrEP effectiveness, comfort in caring for patients living with HIV, or willingness to work in high-HIV-prevalence communities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Impact of Education Exposure\u003c/h2\u003e \u003cp\u003eCompared with those without such education, those who received preclinical HIV/PrEP education were more likely to report feeling moderately to extremely prepared to provide HIV preventative care overall (65% vs. 17%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). They were also more likely to report preparedness to take a comprehensive sexual history (84% vs. 43%, p\u0026thinsp;=\u0026thinsp;0.003). No statistically significant differences were observed between these groups for preparedness to handle PrEP care, discussing other HIV prevention strategies, or integrating PrEP discussions into routine healthcare visits. With respect to attitudes and beliefs (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), respondents who had received HIV/PrEP education were more likely to strongly agree that PrEP is an effective method of HIV prevention (77% vs. 52%, p\u0026thinsp;=\u0026thinsp;0.025). No statistically significant differences were observed for the perceived importance of hands-on experience, comfort caring for patients living with HIV, or willingness to work in high-HIV-prevalence areas.\u003c/p\u003e \u003cp\u003eAmong respondents who had received HIV/PrEP education, the perceived adequacy of education was associated with preparedness outcomes (Table\u0026nbsp;5). Higher perceived adequacy corresponded to greater reported preparedness to handle PrEP care (p\u0026thinsp;=\u0026thinsp;0.0004), integrate PrEP discussions into routine visits (p\u0026thinsp;=\u0026thinsp;0.002), and provide HIV preventative care overall (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Preparedness to take a comprehensive sexual history and to discuss other prevention strategies did not differ significantly by perceived education adequacy.\u003c/p\u003e \u003cp\u003eThe associations between perceived education adequacy and attitudes or comfort levels are shown in Table\u0026nbsp;5. The respondents who perceived their education as adequate were more likely to report being comfortable with patients living with HIV (p\u0026thinsp;=\u0026thinsp;0.022). No statistically significant associations were observed for perceived importance of hands-on experience, belief in PrEP effectiveness, or willingness to work in high-HIV-prevalence communities.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between Preclinical HIV/PrEP Education and Student Preparedness and Attitudes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSurvey Item\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eReceived Education (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNo Education (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHandle PrEP care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTake sexual history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscuss other prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntegrate PrEP discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall preparedness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImportance of hands-on experience\u003c/p\u003e \u003cp\u003e(% very to extremely important)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelief PrEP is effective\u003c/p\u003e \u003cp\u003e(% strongly agree)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.025\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComfort caring for HIV+\u003c/p\u003e \u003cp\u003e(% some to extreme comfort)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork in high HIV prevalence area\u003c/p\u003e \u003cp\u003e(% Yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Statistically significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 using Fisher\u0026rsquo;s exact test.\u003c/p\u003e \u003cp\u003e \u003cem\u003ePercent of students who felt \u0026ldquo;Moderately to Extremely Prepared\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;5: Association between the Perceived Adequacy of Education and the Clinical Preparedness of Students who Felt Moderately to Extremely Prepared\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSurvey Item\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eEducation Inadequate (Disagree) (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eEducation Neutral (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eEducation Adequate (Agree) (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHandle PrEP care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0004\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTake sexual history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscuss other prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.087\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntegrate PrEP discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Preparedness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImportance of hands-on experience\u003c/p\u003e \u003cp\u003e(% Very to Extremely Important)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelief PrEP is effective\u003c/p\u003e \u003cp\u003e(% Strongly Agree)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComfort caring for HIV+ patients\u003c/p\u003e \u003cp\u003e(% Some to Extreme Comfort)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.022\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork in high HIV prevalence area\u003c/p\u003e \u003cp\u003e(% Yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Statistically significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 using Fisher\u0026rsquo;s exact test.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study assessed osteopathic medical students' preparedness to provide HIV prevention and PrEP care, with attention to regional differences, training stages, and educational exposure. While differences were observed between students at the two participating programs, these findings are best interpreted in the context of curricular structure and educational emphasis rather than geographic region alone. Across both schools, students demonstrated strong interest in HIV prevention but limited hands-on experience. Progression through medical school improved some general clinical skills but did not lead to increased preparedness for PrEP-specific care. Exposure to HIV and PrEP education was associated with greater overall preparedness and greater belief in PrEP effectiveness but did not consistently improve confidence in performing PrEP-related clinical tasks. These findings indicate a need for curricula to include more hands-on training and standardized educational benchmarks to ensure that all medical students achieve a baseline level of competence in PrEP and sexual health care.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Institutional Differences in Preparedness\u003c/h2\u003e \u003cp\u003eStudents at the southern institution reported greater preparedness across several PrEP-related clinical domains than did those at the midwestern institution. However, given that only one medical school from each region was included, these differences should not be interpreted as regional effects. Instead, they are more likely to reflect differences in institutional curricula, instructional emphasis, and the reinforcement of HIV prevention concepts. The southern institution\u0026rsquo;s location in a high-HIV-burden area may contribute to greater curricular prioritization of HIV prevention, offering a model that could be adapted by other medical schools regardless of geographic location.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.2. The experiential gap\u003c/h2\u003e \u003cp\u003eFew students at either institution reported receiving hands-on training or clinical experience with HIV prevention or PrEP care. Most students identified hands-on experience as important, highlighting a gap between current instruction methods and students' educational needs. While didactic instruction provides foundational knowledge, experiential learning is necessary to develop the communication, counseling, and clinical decision-making skills required for effective PrEP and overall sexual health care.\u003c/p\u003e \u003cp\u003eThe limited clinical exposure reported by students suggests that opportunities to apply PrEP-related knowledge during rotations are inconsistent or infrequent. Without structured clinical experiences or supervised practices, students may graduate from medical schools with knowledge of PrEP but lack confidence in initiating discussions, assessing patient eligibility, or managing follow-up care. Addressing this gap will require integrating experiential learning opportunities, including standardized patient encounters, simulation exercises, and required clinical objectives, into core clinical rotations. Studies have shown that hands-on training with standardized patients in observed structured clinical examinations (OSCEs) or other simulation-based clinical encounters improves sexual history-taking and HIV-related care (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). These findings suggest that didactic exposure alone, without the intentional integration of experiential learning into the curriculum, is insufficient to ensure competence in PrEP delivery, regardless of training location.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Preparedness by training stage\u003c/h2\u003e \u003cp\u003eDifferences by training stage revealed a mixed pattern. Clinical students reported greater preparedness to have a comprehensive sexual history. This is to be expected with increased patient contact and repetition of general clinical skills during rotations. In contrast, preclinical students reported greater preparedness to integrate PrEP discussions into routine healthcare visits.\u003c/p\u003e \u003cp\u003eThis difference may reflect the perspectives of early versus advanced trainees. Preclinical students, with recent classroom-based exposure to PrEP, may find discussions of PrEP more straightforward. Clinical students who face time constraints and more complex patient interactions may find incorporating PrEP conversations into routine care more challenging. Overall preparedness and ability to provide PrEP care did not differ significantly by training level. One reason is that PrEP-specific skills are not reinforced as students progress through medical school. Research has shown that one year after receiving basic science knowledge, two-thirds to three-fourths of that knowledge remains. However, this percentage decreases to less than 50% at two years post-receiving (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). This may explain why preclinical students feel better prepared to integrate PrEP discussions, as they are most familiar with the patients who would benefit most from this prevention strategy. Regardless, increased exposure to information regarding HIV prevention and PrEP has been shown to improve physician willingness to prescribe (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). As physicians specialize, the education and training they receive after medical school in HIV prevention are variable. Medical school preclinical training provides the opportunity for a common educational framework for future physicians. It should attempt to target public health information, such as HIV and sexually transmitted infection (STI) prevention and PrEP.\u003c/p\u003e \u003cp\u003eAdditionally, as students encounter patients for the first time, their level of confidence in discussing sexual health topics diminishes. While students may feel confident in discussing PrEP in theory, they lose confidence when it is time to put their learning into clinical practice. This lack of confidence can also extend into residency training (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Together, these findings suggest that early curricular exposure may increase confidence in PrEP-related concepts. However, without longitudinal reinforcement and applied practice, this confidence may diminish as students transition into more complex clinical environments.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.4. Impact of Educational Exposure\u003c/h2\u003e \u003cp\u003eExposure to preclinical HIV/PrEP education was associated with greater overall preparedness to provide HIV preventative care and greater confidence in having a comprehensive sexual history. Students who had received formal education were also more likely to strongly endorse the effectiveness of PrEP. These findings indicate that existing curricula successfully convey the conceptual importance and scientific basis of HIV prevention.\u003c/p\u003e \u003cp\u003eHowever, educational exposure alone did not result in significantly greater preparedness to manage PrEP care or to include PrEP discussions in routine visits. Even students who considered their education adequate showed differences in preparedness across clinical tasks. These findings suggest that preclinical instruction provides a foundation, but additional applied training is needed to develop practical competence in PrEP delivery. To assess this ability, methods such as objective structured clinical examinations (OSCEs) and simulated clinical encounters could be used. These techniques would allow educators to evaluate and provide feedback on students' practical skills in real-world settings while giving students opportunities to practice these skills in a low-stakes environment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.5. Implications for Medical Education\u003c/h2\u003e \u003cp\u003eThe findings of this study highlight the importance of early, structured, longitudinal HIV and PrEP education within medical school curricula. Differences in preparedness between institutions appear to be driven more by curricular emphasis than by student attitudes or motivation. Medical schools that prioritize HIV prevention\u0026mdash;particularly through early academic instruction paired with experiential learning\u0026mdash;may better prepare students to engage in PrEP discussions, manage preventive care, and address sexual health confidently in clinical practice.\u003c/p\u003e \u003cp\u003eCurricula that include experiential learning and repeated clinical application, in addition to didactic instruction, may help students apply knowledge in practice. The inclusion of PrEP-related objectives in core clinical rotations and the use of structured teaching methods may better prepare students to provide HIV prevention care in various practice settings.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Limitations","content":"\u003cp\u003eThis study has several limitations. Although the response rate was low, it is comparable to other voluntary survey-based studies of medical students and may reflect survey fatigue in this population. The use of a convenience sample from two medical schools limits generalizability, and the low response rate raises the possibility of response bias. Preparedness was self-reported and may not reflect objective clinical competence. Additionally, causal inferences cannot be drawn due to the cross-sectional design. Despite these limitations, the study provides insight into how educational exposure, training stage, and regional context relate to medical student preparedness for HIV prevention and PrEP care. These findings highlight areas for improvement in medical education and suggest a need for more consistent HIV prevention training across diverse educational settings. Addressing similar educational gaps could help institutions better prepare students for the challenges of HIV prevention and PrEP care. Additionally, because only one institution per region was included, the observed differences should be interpreted as institutional rather than regional, and future studies should include multiple schools per region to better assess geographic trends.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eThis study identifies both strengths and gaps in medical student preparedness for HIV prevention and PrEP care. Students demonstrate strong interest and positive attitudes toward caring for people affected by HIV, but there are ongoing deficiencies in hands-on training and variability in preparedness. Addressing these gaps with standardized, experiential, and ongoing educational strategies may better prepare future physicians to support efforts to reduce the impact of the HIV epidemic.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEHE: Ending the HIV Epidemic in the United States\u003c/p\u003e\n\u003cp\u003eHHS: United States Department of Health and Human Services\u003c/p\u003e\n\u003cp\u003eHIV: Human immunodeficiency virus\u003c/p\u003e\n\u003cp\u003eMSM: Men who have sex with men\u003c/p\u003e\n\u003cp\u003eOSCE: Objective structured clinical examination\u003c/p\u003e\n\u003cp\u003ePrEP: Pre-exposure prophylaxis\u003c/p\u003e\n\u003cp\u003eSTI: Sexually transmitted infection\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate:\u003c/h2\u003e\n\u003cp\u003eThe Institutional Review Board at the Alabama College of Osteopathic Medicine reviewed the protocol and determined that the study was exempt from full review (24-07-09-001-ACOM). The study was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all participants, and consent was implied by voluntary completion and submission of the anonymous survey.\u003c/p\u003e\n\u003ch2\u003eConsent for publication:\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eCompeting interests:\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eKR and CB developed the survey. ZM assisted in reviewing and deploying the survey. RG analyzed and interpreted data from the survey. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eU.S. Department of Health and Human Services. Overview: Ending the HIV Epidemic in the U.S. U.S. Department of Health and Human Services: U.S. Department of Health and Human Services. 2023. https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview. Accessed 5 Jul 2024.\u003c/li\u003e\n\u003cli\u003eGreenwood GL, Wilson A, Bansal GP, Barnhart C, Barr E, Berzon R, et al. HIV-Related Stigma Research as a Priority at the National Institutes of Health. AIDS and Behavior. 2022;26:5-26.\u003c/li\u003e\n\u003cli\u003eCooper RL, Tabatabai M, Juarez PD, Ramesh A, Morris MC, Brown KY, et al. Pre-Exposure Prophylaxis Training among Medical Schools in the United States. Journal of Primary Care and Community Health. 2021;12.\u003c/li\u003e\n\u003cli\u003eHaist SA, Griffith IC, Hoellein AR, Talente G, Montgomery T, Wilson JF. Improving students\u0026apos; sexual history inquiry and HIV counseling with an interactive workshop using standardized patients. J Gen Intern Med. 2004;19(5 Pt 2):549-53.\u003c/li\u003e\n\u003cli\u003ePetroll AE, Walsh JL, Owczarzak JL, McAuliffe TL, Bogart LM, Kelly JA. PrEP Awareness, Familiarity, Comfort, and Prescribing Experience among US Primary Care Providers and HIV Specialists. AIDS and Behavior. 2017;21(5):1256-67.\u003c/li\u003e\n\u003cli\u003eBeer L, Tie Y, McCree DH, Demeke HB, Marcus R, Padilla M, et al. 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J Health Care Poor Underserved. 2020;31(1):235-48.\u003c/li\u003e\n\u003cli\u003eCahill S, Taylor SW, Elsesser SA, Mena L, Hickson D, Mayer KH. Stigma, medical mistrust, and perceived racism may affect PrEP awareness and uptake in black compared to white gay and bisexual men in Jackson, Mississippi and Boston, Massachusetts. AIDS Care. 2017;29(11):1351-8.\u003c/li\u003e\n\u003cli\u003eCenters for Disease Control and Prevention. Diagnoses, deaths, and prevalence of HIV in the United States and 6 territories and freely associated states, 2022. Centers for Disease Control and Prevention May 2024. http://www.cdc.gov/hiv-data/nhss/hiv-diagnoses-deaths-prevalence.html. Accessed 11 Nov 2025.\u003c/li\u003e\n\u003cli\u003eU.S. Department of Health and Human Services. Statistics: HIV Basics HIV.gov: U.S. Department of Health and Human Services; 2023. https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics. 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An assessment of health-care students\u0026apos; attitudes toward patients with or at high risk for HIV: Implications for education and cultural competency. AIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV. 2014;26(10):1223-8.\u003c/li\u003e\n\u003cli\u003eAlabama College of Osteopathic Medicine. Class of 2025. Visme. 2021. https://my.visme.co/view/z4pqovxo-class-of-2025. Accessed 11 Nov 2025. \u003c/li\u003e\n\u003cli\u003eAlabama College of Osteopathic Medicine. Class of 2028. Visme. 2024. https://my.visme.co/view/pvpdy0oe-class-of-2028. Accessed 11 Nov 2025.\u003c/li\u003e\n\u003cli\u003eAlabama College of Osteopathic Medicine. Class of 2027. Visme. 2023 https://my.visme.co/view/1jxyx4vm-class-of-2027. Accessed 11 Nov 2025.\u003c/li\u003e\n\u003cli\u003eAlabama College of Osteopathic Medicine. Class of 2026. Visme. 2022 https://my.visme.co/view/4dvw0q3y-class-of-2026. Accessed 11 Nov 2025.\u003c/li\u003e\n\u003cli\u003eMarian University Tom and Julie Wood College of Osteopathic Medicine. DO Class of 2025 Profile: Marian University Tom and Julie Wood College of Osteopathic Medicine. 2021. https://www.marian.edu/osteopathic-medical-school/_assets/_documents/mucom-class-of-2025-profile-sheet.pdf. Accessed 11 Nov 2025.\u003c/li\u003e\n\u003cli\u003eMarian University Tom and Julie Wood College of Osteopathic Medicine. DO Class of 2028 Profile: Marian University Tom and Julie Wood College of Osteopathic Medicine. 2024. https://www.marian.edu/osteopathic-medical-school/_assets/_documents/do-profile-sheet-class-of-2028.pdf. Accessed 11 Nov 2025.\u003c/li\u003e\n\u003cli\u003eMarian University Tom and Julie Wood College of Osteopathic Medicine. DO Class of 2027 Profile: Marian University Tom and Julie Wood College of Osteopathic Medicine. 2023. https://www.marian.edu/osteopathic-medical-school/_assets/_documents/do-profile-sheet-class-of-20271.pdf. Accessed 11 Nov 2025.\u003c/li\u003e\n\u003cli\u003eMarian University Tom and Julie Wood College of Osteopathic Medicine. DO Class of 2026 Profile: Marian University Tom and Julie Wood College of Osteopathic Medicine. 2022. https://www.marian.edu/osteopathic-medical-school/_assets/_documents/do-profile-sheet-class-of-2026-high-res.pdf. Accessed 11 Nov 2025.\u003c/li\u003e\n\u003cli\u003eAlabama College of Osteopathic Medicine. Residency \u0026amp; Match Data: Alabama College of Osteopathic Medicine. 2025. https://www.acom.edu/residency-match-data/. Accessed 11 Nov 2025.\u003c/li\u003e\n\u003cli\u003eMarian University Tom and Julie Wood College of Osteopathic Medicine. Class of 2025 Residency Placement: Marian University Tom and Julie Wood College of Osteopathic Medicine. 2025 https://www.marian.edu/osteopathic-medical-school/_assets/_documents/do-residency-placement-sheet-class-of-2025.pdf. Accessed 11 Nov 2025.\u003c/li\u003e\n\u003cli\u003eCusters E. Long-term retention of basic science knowledge: a review study. Adv Health Sci Educ Theory Pract. 2010;15(1):109-28.\u003c/li\u003e\n\u003cli\u003eKrakower DS, Mayer KH. The role of healthcare providers in the roll out of preexposure prophylaxis. Curr Opin HIV AIDS. 2016;11(1):41-8.\u003c/li\u003e\n\u003cli\u003eBeebe S, Payne N, Posid T, Diab D, Horning P, Scimeca A, et al. The Lack of Sexual Health Education in Medical Training Leaves Students and Residents Feeling Unprepared. J Sex Med. 2021;18(12):1998-2004.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Experiential learning, Undergraduate medical education, Clinical preparedness, Medical student preparedness, Pre-exposure prophylaxis (PrEP), HIV prevention education, Osteopathic medical students","lastPublishedDoi":"10.21203/rs.3.rs-8641255/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8641255/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Pre-exposure prophylaxis (PrEP) is a highly effective strategy for HIV prevention, yet its uptake remains limited in part due to gaps in provider preparedness. Medical school represents a critical opportunity to prepare future physicians to deliver HIV preventive care; however, variability in curricular exposure and clinical training may result in uneven preparedness among graduating students.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: An anonymous, cross-sectional survey was administered to osteopathic medical students (years 1–4) at two U.S. medical schools. The survey assessed exposure to HIV/PrEP education, perceived clinical preparedness, and professional attitudes toward HIV and PrEP. Preparedness and attitudes were compared by institution, training stage (preclinical vs. clinical), and educational exposure using Fisher’s exact test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A total of 122 students completed the survey (response rate 8.7%). 70% percent reported receiving preclinical HIV/PrEP education, yet only 16.8% reported any hands-on experience in HIV prevention or care. Students at one institution reported significantly greater preparedness across multiple domains, including overall HIV preventive care (65% vs. 26%, p \u0026lt; 0.0001), handling PrEP care, and taking a comprehensive sexual history. Clinical students reported greater preparedness for sexual history taking, whereas preclinical students reported greater preparedness to integrate PrEP discussions into routine visits. Receipt of HIV/PrEP education was associated with greater overall preparedness and stronger belief in PrEP effectiveness, but not with consistent preparedness across PrEP-specific clinical tasks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Medical students demonstrate strong awareness of HIV prevention but limited experiential training and variable preparedness for PrEP-specific care. Early curricular exposure improves perceived preparedness and confidence; however, inconsistent longitudinal reinforcement and lack of hands-on training highlight the need for standardized, competency-based, and experiential HIV/PrEP education across medical curricula to better prepare future physicians.\u003c/p\u003e","manuscriptTitle":"Assessing Osteopathic Medical Student Preparedness for Pre-Exposure Prophylaxis (PrEP) and HIV Prevention Care at Two U.S. Medical Schools","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-20 15:35:26","doi":"10.21203/rs.3.rs-8641255/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"152595232212137613754719424333885888085","date":"2026-02-17T23:44:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-17T10:08:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-16T12:59:22+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-27T07:40:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-24T17:07:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-01-24T17:00:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6ccad4dc-a6d6-4674-aa81-4a036f7103e7","owner":[],"postedDate":"February 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-20T15:35:26+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-20 15:35:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8641255","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8641255","identity":"rs-8641255","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}