Addressing Gaps in HIV Preexposure Prophylaxis Care to Reduce Racial Disparities in HIV Incidence in the United States

Samuel M. Jenness; Kevin M. Maloney; Dawn K. Smith; Karen W. Hoover; Steven M. Goodreau; Eli S. Rosenberg; Kevin M. Weiss; Albert Y. Liu; Darcy W. Rao; Patrick S. Sullivan

Disclosures

Am J Epidemiol. 2019;188(4):743-752.

Conclusions

PrEP will play a critical role in HIV elimination in the United States, but its success will also depend on how we use it to address the persistent racial disparities in HIV incidence. Implementation of PrEP following a continuum framework could achieve the dual goals of reducing HIV incidence overall and decreasing the disparities in incidence between BMSM and WMSM over the next decade even despite current racial gaps in PrEP care. However, targeting these gaps with existing and novel interventions is greatly needed to make critical advances in using PrEP to reduce disparities.

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Abbreviations
BMSM, black men who have sex with men; CrI, credible interval; HIV, human immunodeficiency virus; MSM, men who have sex with men; NNT, number needed to treat; PrEP, preexposure prophylaxis; PYAR, person-years at risk; WMSM, white men who have sex with men.

Acknowledgments
This work was supported by Centers for Disease Control and Prevention (grant U38 PS004646), and by the National Institutes of Health (grants R21 MH112449, R21 HD075662, P30 AI050409, and P30 AI027757).
We thank members of the scientific and public health advisory groups of the Coalition for Applied Modeling for Prevention project for their input on this study, and specifically those members who reviewed a previous version of this manuscript: Drs. Gregory Felzien and Jane Kelly.
The findings and conclusions in this paper are those of the authors and do not necessarily represent the views of the US National Institutes of Health or Centers for Disease Control and Prevention.

Table 1. Projected Impact, Using Simulated Data, of Changes to Individual Preexposure-Prophylaxis Care-Continuum Steps for Black Men Who Have Sex with Men on Human Immunodeficiency Virus Outcomes among Black Men Who Have Sex with Men
Scenario	% On PrEP		HIV Prevalence		HIV Incidence		HR		PIA
Scenario	Estimate	95% CrI	Estimate	95% CrI	Estimate	95% CrI	Estimate	95% CrI	Estimate	95% CrI
Referent (no PrEP)	0.0	0.0, 0.0	45.2	43.0, 47.4	7.73	6.51, 9.07
Aware of PrEP
30%	5.0	4.3, 5.5	41.8	39.8, 43.8	6.54	5.47, 7.68	0.85	0.68, 1.09	9.3	1.8, 15.3
50% (observed B and W)^a,b	8.4	7.7, 9.1	39.9	38.1, 41.6	5.88	4.66, 7.05	0.77	0.57, 0.99	14.1	8.2, 21.0
70%	12.0	11.2, 12.8	37.7	35.7, 39.5	5.24	4.43, 6.25	0.68	0.55, 0.88	20.0	13.8, 26.9
90%	15.6	14.8, 16.5	35.9	34.2, 37.8	4.68	3.88, 5.57	0.61	0.48, 0.78	25.0	18.7, 30.4
Access to PrEP: awareness
50%	5.4	4.9, 5.9	41.4	39.6, 43.3	6.43	5.30, 7.52	0.84	0.65, 1.06	10.1	3.3, 16.4
76% (observed B)^a	8.4	7.7, 9.1	39.9	39.1, 41.6	5.88	4.66, 7.05	0.77	0.57, 0.99	14.1	8.2, 21.0
85%	9.4	8.8, 10.1	39.1	37.5, 41.0	5.65	4.73, 6.81	0.73	0.58, 0.95	15.9	10.3, 22.4
95% (observed W)^b	10.6	9.9, 11.5	38.5	36.3, 40.3	5.54	4.56, 6.48	0.72	0.56, 0.94	18.2	10.8, 24.9
Prescribed PrEP: access
50%	7.2	6.5, 7.8	40.4	38.4, 42.2	6.14	5.13, 7.02	0.81	0.64, 0.99	12.9	4.8, 18.5
63% (Obs B)^a	8.4	7.7, 9.1	39.9	38.1, 41.6	5.88	4.66, 7.05	0.77	0.57, 0.99	14.1	8.2, 21.0
73% (Obs W)^b	9.2	8.5, 9.9	39.5	37.6, 41.3	5.83	4.84, 6.90	0.75	0.59, 0.98	15.4	8.8, 21.7
85%	10.1	9.4, 10.9	38.9	36.8, 40.5	5.64	4.54, 6.73	0.74	0.54, 0.95	17.3	9.5, 23.4
Full adherence: prescription
50%	8.3	7.7, 8.9	39.8	38.1, 41.8	5.98	4.78, 7.04	0.78	0.58, 1.02	14.2	6.0, 20.5
59.8% (observed B)^a	8.4	7.7, 9.1	39.9	38.1, 41.6	5.88	4.66, 7.05	0.77	0.57, 0.99	14.1	8.2, 21.0
75%	8.6	7.8, 9.2	39.3	37.2, 41.1	5.7	4.61, 6.73	0.75	0.56, 0.93	15.6	9.9, 23.3
93% (observed W)^b	8.8	8.1, 9.4	38.9	37.0, 40.6	5.59	4.66, 6.78	0.74	0.58, 0.95	16.5	10.1, 22.6
Time on PrEP before discontinuation: prescription
1 year	7.9	7.2, 8.6	40.1	37.9, 42.0	5.97	4.89, 7.02	0.78	0.60, 0.99	13.7	7.6, 20.0
1.1 years (observed B)^a	8.4	7.7, 9.1	39.9	38.1, 41.6	5.88	4.66, 7.05	0.77	0.57, 0.99	14.1	8.2, 21.0
2 years	10.7	9.9, 11.4	38.6	36.8, 40.6	5.45	4.41, 6.69	0.71	0.54, 0.93	17.5	11.0, 23.7
3.16 years (observed W)^b	12.3	11.6, 13.0	37.8	35.6, 39.4	5.23	4.11, 6.22	0.68	0.52, 0.87	20	13.5, 26.8

Abbreviations: B, black; BMSM, black men who have sex with men; CrI, credible interval; HIV, human immunodeficiency virus; HR, hazard ratio; PIA, percent of infections averted; PrEP, preexposure prophylaxis; W, white; WMSM, white men who have sex with men.
^aObserved PrEP continuum value for BMSM, using data from 2 studies of HIV disparities between younger BMSM and WMSM in Atlanta, our target population (22, 36).
^bObserved PrEP continuum value for WMSM, using data from 2 studies of HIV disparities between younger BMSM and WMSM in Atlanta, our target population (22, 36).

Table 2. Projected Impact, Using Simulated Data, of Changes to Joint Preexposure-Prophylaxis Care-Continuum Steps for Black Men Who Have Sex with Men on Human Immunodeficiency Virus Outcomes for Black and White Men Who Have Sex with Men
Scenario^a	BMSM Outcomes						WMSM Outcomes						Disparity Indices
	% On PrEP		HIV Incidence		Hazard Ratio		% On PrEP		HIV Incidence		Hazard Ratio		Absolute^b	Relative^c	Prevention^d
	Estimate	95% CrI	Estimate	95% CrI	Estimate	95% CrI	Estimate	95% CrI	Estimate	95% CrI	Estimate	95% CrI	Estimate	Estimate	Estimate
Referent (no PrEP)	0.0	0.0, 0.0	7.73	6.51, 9.07			0.00	0.0, 0.0	1.65	1.27, 2.07			6.08	4.68
Combined PrEP continuum for black MSM
Observed B × 50% relative	0.8	0.6, 0.9	7.38	6.20, 8.69	0.97	0.74, 1.19	23.4	22.3, 24.5	1.00	0.69, 1.32	0.61	0.40, 0.88	6.38	7.38	0.36
Observed B	8.4	7.7, 9.1	5.88	4.66, 7.05	0.77	0.57, 0.99	23.4	22.4, 24.4	0.93	0.68, 1.23	0.56	0.40, 0.86	4.95	6.32	0.21
Observed W	17.7	16.8, 18.7	4.15	3.36, 4.98	0.53	0.43, 0.70	23.4	22.2, 24.5	0.85	0.59, 1.15	0.52	0.34, 0.79	3.30	4.88	0.01
Observed B × 150% relative	27.2	26.1, 28.4	3.06	2.33, 3.80	0.39	0.29, 0.51	23.5	22.4, 24.5	0.77	0.47, 1.10	0.47	0.28, 0.73	2.29	3.97	−0.08
Observed B × 200% relative	42.1	40.8, 43.4	1.73	1.33, 2.17	0.22	0.17, 0.32	23.5	22.4, 24.6	0.69	0.48, 0.99	0.42	0.27, 0.66	1.04	2.51	−0.2

Abbreviations: B, black; BMSM, black men who have sex with men; CrI, credible interval; HIV, human immunodeficiency virus; PrEP, preexposure prophylaxis; W, white; WMSM, white men who have sex with men.
^aObserved data from 2 studies of HIV disparities between younger BMSM and WMSM in Atlanta, our target population (22, 36).
^bAbsolute disparity index = BMSM HIV incidence − WMSM HIV incidence.
^cRelative disparity index = BMSM HIV incidence ÷ WMSM HIV incidence.
^dPrevention index = BMSM hazard ratio − WMSM hazard ratio.

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