Geographic Access to Preexposure Prophylaxis Clinics Among Men Who Have Sex With men in the United States

Aaron J. Siegler, PhD, MHS; Anna Bratcher, MSPH; Kevin M. Weiss, MPH

Disclosures

Am J Public Health. 2019;109(9):1216-1223. 

In This Article

Abstract and Introduction

Abstract

Objectives: To explore US geographic areas with limited access to HIV preexposure prophylaxis (PrEP) providers, PrEP deserts.

Methods: We sourced publicly listed PrEP providers from a national database of PrEP providers from 2017 and obtained county-level urbanicity classification and population estimates of men who have sex with men (MSM) from public data. We calculated travel time from census tract to the nearest provider. We classified a census tract as a PrEP desert if 1-way driving time was greater than 30 or 60 minutes.

Results: One in 8 PrEP-eligible MSM (108 758/844 574; 13%) lived in 30-minute-drive deserts, and a sizable minority lived in 60-minute-drive deserts (38 804/844 574; 5%). Location in the South and lower urbanicity were strongly associated with increased odds of PrEP desert status.

Conclusions: A substantial number of persons at high risk for HIV transmission live in locations with no nearby PrEP provider. Rural and Southern areas are disproportionately affected.

Public Health Implications: For maximum implementation effectiveness of PrEP, geography should not determine access. Programs to train clinicians, expand venues for PrEP care, and provide telemedicine services are needed.

Introduction

In the United States, men who have sex with men (MSM) account for a disproportionate proportion of HIV transmission.[1] Easily accessible combination prevention strategies are needed to effectively address the HIV pandemic.[2] HIV preexposure prophylaxis (PrEP), the provision of antiretroviral medication as a prophylactic measure for at-risk, HIV-uninfected individuals, is highly effective in preventing HIV transmission in clinical trials and clinical practice settings.[3–5] Implementation of PrEP programs for populations with highest incidence is critical to reducing new infections in the United States; however, challenges have been observed in translating PrEP interest into PrEP uptake.[6,7]

The US Public Health Service provides guidelines for PrEP that recommend 4 annual visits with a licensed provider for HIV testing and prescription refill,[8] making physical access to providers an important component of PrEP access. A number of factors are strongly associated with uptake of and retention in PrEP care, such as cost for medical services,[6,9,10] race,[9] and insurance.[7] To ensure that PrEP reaches less advantaged groups that are often most in need of the service, novel programs and research will be needed.[11]

Several systematic reviews have found negative associations between length of travel and health outcomes.[12–14] One covered 108 publications spanning a broad array of health domains, from dental care to sleep apnea to HIV care; it found that more than three quarters of the studies identified an association between greater distance or travel time to care and negative health outcomes.[13] A review of 27 cancer studies with more than 700 000 patients concluded that greater distance was associated with more advanced disease at diagnosis (potentially indicating lower use of preventive services), less appropriate treatment strategies, and worse prognoses.[14] One HIV care study found that an intervention that decreased transit time to care resulted in a 10% absolute increase in the number of patients achieving the targeted number of annual HIV clinic visits.[15] Geographic proximity may be especially impactful for prevention services such as PrEP relative to treatment services considered by many previous studies; treatment services that yield immediate, more visible benefits are likely to have higher demand than the invisible benefits of prevention services.[12]

We previously described the density of PrEP-providing clinics at state and county levels, finding that counties with higher proportions of residents living in poverty, lacking health insurance, or identifying as African American or Latino had lower PrEP clinic density when epidemic burden was taken into account.[16] Using a national database of PrEP providers and public data sources, we sought to build on this work by identifying geographic areas without nearby PrEP providers and providing minimum estimates of the number of PrEP-eligible MSM facing geographic barriers to accessing PrEP. This study defines these limited-access areas as PrEP deserts, identifying geographic and sociodemographic correlates to explicate and highlight access inequities.

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