Most gay and bisexual men of all racial and ethnic groups are now aware of pre-exposure prophylaxis (PrEP) to prevent HIV, but Black and Latino men are less likely than white men to have discussed PrEP with a health care provider and to have used it within the past year, according to a recent report from the Centers for Disease Control and Prevention (CDC).
As described in the September 20 edition of the CDC’s Morbidity and Mortality Weekly Report (MMWR), an analysis of data from 23 cities showed that 42% of white men who have sex with men (MSM) reported taking PrEP within the past year, compared with 30% of Latino men and 26% of Black men.
“To expand PrEP use, interventions to increase PrEP awareness, encourage health care providers to discuss PrEP, destigmatize PrEP use and promote racial/ethnic equity in PrEP access are needed,” the study authors concluded.
The Food and Drug Administration approved daily Truvada (tenofovir disoproxil fumarate/emtricitabine) for HIV prevention in 2012. Since then, the number of people using PrEP has risen steadily but unevenly across population groups.
CDC researchers previously reported that in 2015, over 1.1 million people in the United States were at substantial risk of acquiring HIV but only 8% of all eligible individuals were using PrEP, falling to just 3% among Latinos and 1% among African-Americans—the group with the highest rate of new diagnoses. However, these figures included at-risk heterosexual men and women, who are less likely to know about PrEP than gay and bi men.
In the July 12 MMWR, CDC researchers reported that nine out of 10 gay and bi men are aware of PrEP and over a third of those at risk were using it in 2017, up from just 6% five years ago. However, they found that while there were increases in all groups, Black and Latino men were less likely to know about PrEP and less likely to use it than white men.
In the latest report, the authors looked in more detail at the PrEP continuum of care, which starts with learning about PrEP, proceeds to discussing it with a provider, and culminates in a deciding to take PrEP and obtaining Truvada.
Dafna Kanny, PhD, and colleagues from the CDC’s Division of HIV/AIDS Prevention analyzed National HIV Behavioral Surveillance data collected in 2017 from more than 10,000 sexually active MSM in 23 urban areas across the United States: Atlanta, Baltimore, Boston, Chicago, Dallas, Denver, Detroit, Houston, Los Angeles, Memphis, Miami, New Orleans, New York City, Nassau and Suffolk counties in New York, Newark, Philadelphia, Portland (Oregon), San Diego, San Francisco, Seattle, Virginia Beach, Washington, DC, and San Juan, Puerto Rico.
Eligible participants were age 18 or older, born male and identified as men and reported having ever had oral or anal sex with another man. They completed standardized questionnaires in English or Spanish administered in person by trained interviewers. They were offered anonymous HIV testing and given cash or gift cards for doing the interview and test.
This analysis was limited to 4,056 MSM who tested negative for HIV and met the indications for PrEP— for example, having multiple sex partners, a known HIV-positive partner or a recent sexually transmitted infection. Of these, 1,843 (45%) were white, 1,251 (31%) were Latino and 926 (23%) were Black.
The interviews revealed that 95% of white men, 87% of Latino men and 86% of Black men were aware of PrEP. However, just 58% of white men, 44% of Latino men and 43% of Black men said they had discussed PrEP with a health care provider within the past year.
Overall, 42% of white men, 30% of Latino men and 26% of Black men reported that they had taken PrEP within the past year. Among those who had discussed PrEP with a provider, 68%, 62% and 55%, respectively, went on to use PrEP. The disparity between white and Black MSM persisted among those with health insurance and a usual source of health care.
In summary, white MSM were significantly more likely than either Latino or Black men to report PrEP awareness, discussion with a provider and PrEP use, meaning the differences were probably not attributable to chance alone.
Because disparities emerged at the point of discussion with a health care provider, interventions to increase PrEP awareness and discussion should include both at-risk individuals and providers, the study authors recommended. The CDC’s “Start Talking. Stop HIV.” campaign encourages gay and bi men to discuss PrEP with their providers and sexual partners.
PrEP use among those without health insurance was low across all racial/ethnic groups, but among those who discussed PrEP with their provider, the disparity between white and Black men persisted, even among those with insurance. This finding, the researchers wrote, “suggests that Black MSM face additional barriers to PrEP use beyond access to health care.”
“Providers might make clinical decisions derived from inaccurate assumptions about racial/ethnic minority patients. This phenomenon can coalesce with patients’ mistrust of health care providers and inhibit discussions about PrEP and, ultimately, use of PrEP among Black and Hispanic MSM,” the authors continued. “Health care provider trainings to promote PrEP discussions might address perceptions and assumptions that often limit their likelihood of discussing PrEP with MSM patients, especially Black MSM.”
“Protecting persons at risk for HIV through effective, proven interventions, such as PrEP, is a pillar of the nation’s ’Ending the HIV Epidemic: A Plan for America initiative,’” the researchers concluded. “Further efforts to improve outcomes along the HIV PrEP continuum of care for all MSM and to address racial/ethnic disparities, particularly in discussion with a health care provider, and use, will be critical to reducing persistent racial/ethnic disparities in HIV incidence. These actions would help achieve the nation’s goal of preventing new HIV infections.”
Click here to read the MMWR report.
Click here to learn more about PrEP.