Changes in HIV Preexposure Prophylaxis Awareness and Use Among Men Who Have Sex With Men — 20 Urban Areas, 2014 and 2017

Teresa Finlayson, PhD; Susan Cha, PhD; Ming Xia, MD; Lindsay Trujillo, MPH; Damian Denson, PhD; Joseph Prejean, PhD; Dafna Kanny, PhD; Cyprian Wejnert, PhD; National HIV Behavioral Surveillance Study Group


Morbidity and Mortality Weekly Report. 2019;68(27):597-603. 

In This Article

Abstract and Introduction


In February 2019, the U.S. Department of Health and Human Services proposed a strategic initiative to end the human immunodeficiency (HIV) epidemic in the United States by reducing new HIV infections by 90% during 2020–2030*.[1] Phase 1 of the Ending the HIV Epidemic initiative focuses on Washington, DC; San Juan, Puerto Rico; and 48 counties where the majority of new diagnoses of HIV infection in 2016 and 2017 were concentrated and on seven states with a disproportionate occurrence of HIV in rural areas relative to other states. One of the four pillars in the initiative is protecting persons at risk for HIV infection using proven, comprehensive prevention approaches and treatments, such as HIV preexposure prophylaxis (PrEP), which is the use of antiretroviral medications that have proven effective at preventing infection among persons at risk for acquiring HIV. In 2014, CDC released clinical PrEP guidelines to health care providers[2] and intensified efforts to raise awareness and increase the use of PrEP among persons at risk for infection, including gay, bisexual, and other men who have sex with men (MSM), a group that accounted for an estimated 68% of new HIV infections in 2016.[3] Data from CDC's National HIV Behavioral Surveillance (NHBS) were collected in 20 U.S. urban areas in 2014 and 2017, covering 26 of the geographic areas included in Phase I of the Ending the HIV Epidemic initiative, and were compared to assess changes in PrEP awareness and use among MSM. From 2014 to 2017, PrEP awareness increased by 50% overall, with >80% of MSM in 17 of the 20 urban areas reporting PrEP awareness in 2017. Among MSM with likely indications for PrEP (e.g., sexual risk behaviors or recent bacterial sexually transmitted infection [STI]), use of PrEP increased by approximately 500% from 6% to 35%, with significant increases observed in all urban areas and in almost all demographic subgroups. Despite this progress, PrEP use among MSM, especially among black and Hispanic MSM, remains low. Continued efforts to improve coverage are needed to reach the goal of 90% reduction in HIV incidence by 2030. In addition to developing new ways of connecting black and Hispanic MSM to health care providers through demonstration projects, CDC has developed resources and tools such as the Prescribe HIV Prevention program to enable health care providers to integrate PrEP into their clinical care.§ By routinely testing their patients for HIV, assessing HIV-negative patients for risk behaviors, and prescribing PrEP as needed, health care providers can play a critical role in this effort.

NHBS staff members in 20 urban areas collected cross-sectional behavioral survey data and conducted HIV testing among MSM at recruitment events using venue-based sampling.[4] Eligible participants** completed a standardized questionnaire administered in person by trained interviewers. All participants were offered anonymous HIV testing and incentives for the interview and HIV test.†† Analysis was limited to eligible participants at risk for HIV infection who were likely to meet clinical indications for PrEP§§.[2] Specifically, the analysis was limited to MSM who had a negative NHBS HIV test result, did not report a previous HIV-positive test result, had either one male sex partner who was HIV-positive or two or more male sex partners in the past 12 months, and reported either condomless anal sex or a bacterial STI (i.e., syphilis, gonorrhea, or chlamydia) in the past 12 months. PrEP awareness and use were measured differently in 2014 and in 2017. In 2014, participants were asked whether they had "ever heard of people who do not have HIV taking anti-HIV medicines, to keep from getting HIV" and whether, in the past 12 months, they had "taken anti-HIV medicines before sex because you thought it would keep you from getting HIV." In 2017, participants were informed that PrEP is an antiretroviral medicine taken for months or years by a person who is HIV-negative to reduce the risk for getting HIV and then asked whether they had ever heard of PrEP and whether, in the past 12 months they had taken PrEP to reduce the risk of getting HIV. Log-linked Poisson regression models with generalized estimating equations clustered on recruitment event were stratified by subgroup to estimate prevalence ratios and 95% confidence intervals (CIs) for PrEP awareness and use by year. Stratified models for each subgroup were adjusted for income, health insurance, and region. Analyses were conducted using SAS software (version 9.4; SAS Institute).

In 2014 and 2017, 18,610 sexually active MSM were interviewed (9,640 in 2014; 8,970 in 2017) in the 20 urban areas. Of those, this analysis is limited to 7,873 MSM (42%) who had a negative HIV test result but were at risk for HIV infection and likely met the clinical indications for PrEP (3,821 [40%] in 2014; 4,052 [45%] in 2017). From 2014 to 2017, awareness of PrEP among these MSM increased overall from 60% to 90% (adjusted prevalence ratio [aPR] = 1.45; 95% CI = 1.41–1.50) and increased in all urban areas and subgroups (Table 1). In 2017, >80% of MSM in 17 of 20 urban areas and in most demographic subgroups were aware of PrEP. From 2014 to 2017, use of PrEP among MSM increased overall from 6% to 35% (aPR = 5.66; 95% CI = 4.85–6.61) and increased in all urban areas and in almost all demographic subgroups (Table 2). Substantial increases in PrEP use occurred among black, Hispanic, and young (aged 18–29 years) MSM from 2014 to 2017. In 2017, the differences in PrEP use between Hispanic (30%) and white (42%) MSM (aPR = 0.91; 95% CI = 0.78–1.06) and between young (32%) and older (38%) MSM (aPR = 0.97; 95% CI = 0.89–1.05) were no longer significant after controlling for income, health insurance, and region. However, the difference in reported PrEP use between black (26%) and white (42%) MSM remained significant after controlling for these three factors (aPR = 0.78; 95% CI = 0.66–0.92). During 2017, PrEP use increased with education and income, and 39% of the MSM who saw a health care provider in the past 12 months reported PrEP use.

The number of U.S. urban areas collecting data differed in 2014 and 2017. The following 20 urban areas collected data both years: Atlanta, Georgia; Baltimore, Maryland; Boston, Massachusetts; Chicago, Illinois; Dallas, Texas; Denver, Colorado; Detroit, Michigan; Houston, Texas; Los Angeles, California; Miami, Florida; Nassau and Suffolk counties, New York; New Orleans, Louisiana; New York City, New York; Newark, New Jersey; Philadelphia, Pennsylvania; San Diego, California; San Francisco, California; San Juan, Puerto Rico; Seattle, Washington; and Washington, DC. The following three urban areas that collected data in 2017 were not included in this analysis: Memphis, Tennessee; Norfolk, Virginia; and Portland, Oregon.
** Men who were born male and identified as male, reported having ever had oral or anal sex with another man, resided in the interview city, were aged ≥18 years, and could complete the interview in English or Spanish.
†† The incentive format (cash or gift card) and amount varied by city according to formative assessment and local policy. A typical format included $25 for completing the interview and $25 for providing a specimen for HIV testing.
§§ NHBS data do not correspond directly with the criteria for PrEP indication in the clinical guidelines. The guidelines recommend that men use PrEP if they are without acute or established HIV infection, have had sex with a nonmonogamous male partner who has not recently tested HIV-negative, and have had at least one of the following: any anal sex without a condom in the past 6 months or a bacterial STI (i.e., syphilis, gonorrhea, or chlamydia) diagnosed or reported in the past 6 months. NHBS data flag persons who are likely indicated for PrEP use because of behavior from a longer period (12 months versus 6 months) and use multiple sex partners as a proxy for a nonmonogamous partner.