Racial/Ethnic Disparities in HIV Preexposure Prophylaxis Among Men Who Have Sex With Men — 23 Urban Areas, 2017

Dafna Kanny, PhD; William L. Jeffries IV, PhD; Johanna Chapin-Bardales, PhD; Paul Denning, MD; Susan Cha, PhD; Teresa Finlayson, PhD; Cyprian Wejnert, PhD; National HIV Behavioral Surveillance Study Group

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(37):801-806. 

In This Article

Abstract and Introduction

Introduction

In 2017, preliminary data show that gay, bisexual, and other men who have sex with men (MSM) accounted for 67% of new diagnoses of human immunodeficiency virus (HIV) infection, that MSM who inject drugs accounted for an additional 3%, and that African American/black (black) and Hispanic/Latino (Hispanic) MSM were disproportionately affected.[1] During 2010–2015, racial/ethnic disparities in HIV incidence increased among MSM; in 2015, rates among black and Hispanic MSM were 10.5 and 4.9 times as high, respectively, as the rate among white MSM (compared with 9.2 and 3.8 times as high, respectively, in 2010).[2] Increased use of preexposure prophylaxis (PrEP), which reduces the risk for sexual acquisition of HIV infection by approximately 99% when taken daily as prescribed,* would help to reduce these disparities and support the Ending the HIV Epidemic: A Plan for America initiative.[3] Although PrEP use has increased among all MSM since 2014,[4] racial/ethnic disparities in PrEP use could increase existing disparities in HIV incidence among MSM.[5] To understand racial/ethnic disparities in PrEP awareness, discussion with a health care provider, and use (steps in the HIV PrEP continuum of care),[6] CDC analyzed 2017 National HIV Behavioral Surveillance (NHBS) data. Black and Hispanic MSM were significantly less likely than were white MSM to be aware of PrEP, to have discussed PrEP with a health care provider, or to have used PrEP within the past year. Among those who had discussed PrEP with a health care provider within the past year, 68% of white MSM, 62% of Hispanic MSM, and 55% of black MSM, reported PrEP use. Prevention efforts need to increase PrEP use among all MSM and target eliminating racial/ethnic disparities in PrEP use.§

Data from CDC's NHBS collected among MSM in 23 U.S. urban areas in 2017 [7] were analyzed to assess racial/ethnic disparities along the HIV PrEP continuum of care. The analysis was limited to participants at risk for HIV infection who likely met clinical indications for PrEP.** Men with a likely indication for PrEP included those who had 1) a negative NHBS HIV test result following the NHBS interview††; 2) either multiple male sex partners or any male sex partner with HIV infection within the past year; and 3) either condomless anal sex or a bacterial sexually transmitted infection§§ within the past year. Participants were asked whether they were aware of PrEP, had discussed PrEP with a health care provider, and had used PrEP within the past year.¶¶ Log-linked Poisson regression models with generalized estimating equations clustered on recruitment event and adjusted for urban area were used to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs). Analyses were conducted using SAS software (version 9.4; SAS Institute).

In 2017, a total of 10,104 sexually active MSM were interviewed in 23 U.S. urban areas. This analysis included 4,056 (40%) MSM (1,843 white MSM, 1,251 Hispanic MSM, and 962 black MSM) who tested negative for HIV and likely met the clinical indications for PrEP. Overall 1,742 (95%) white, 1,088 (87%) Hispanic, and 825 (86%) black MSM were aware of PrEP (white versus Hispanic aPR = 1.1, 95% CI = 1.0–1.1; white versus black aPR = 1.1, 95% CI = 1.0–1.1) (Figure). However, only 1,063 (58%) white, 546 (44%) Hispanic, and 412 (43%) black MSM reported discussing PrEP with a health care provider within the past year (white versus Hispanic aPR = 1.2, 95% CI = 1.1–1.3; white versus black aPR = 1.2, 95% CI = 1.1–1.3). Moreover, only 765 (42%) white, 373 (30%) Hispanic, and 248 (26%) black MSM reported taking PrEP within the past year (white versus Hispanic aPR = 1.2, 95% CI = 1.1–1.3; white versus black aPR = 1.4, 95% CI = 1.2–1.6). White MSM were significantly more likely than were Hispanic and black MSM to report PrEP awareness, discussion with a health care provider, and use.

Figure.

Preexposure prophylaxis (PrEP) awareness,* discussion, and use,§ by race/ethnicity, among men who have sex with men (MSM) with a likely indication for PrEP use (N = 4,056) — 23 urban areas, 2017
Abbreviations: HIV = human immunodeficiency virus; NHBS = National HIV Behavioral Surveillance.
* Respondents with a negative NHBS HIV test result were asked "Preexposure prophylaxis, or PrEP, is an antiretroviral medicine, such as Truvada, taken for months or years by a person who is HIV-negative to reduce the risk of getting HIV. Before today, have you ever heard of PrEP?"
If respondent had heard of PrEP before today, he was asked "In the past 12 months, have you had a discussion with a health care provider about taking PrEP?"
§ If respondent had heard of PrEP before today, he was asked "In the past 12 months, have you taken PrEP to reduce the risk of getting HIV?"
Men with a likely indication for PrEP included those who had 1) a negative NHBS HIV test result following the NHBS interview; 2) either multiple male sex partners or any male sex partner with HIV infection within the past year; and 3) either condomless anal sex or a bacterial sexually transmitted infection within the past year.

Among 2,021 MSM who discussed PrEP with their health care provider, 225 of 412 (55%) black MSM used PrEP, compared with 338 of 546 (62%) Hispanic MSM and 724 of 1,063 (68%) white MSM (Table). White MSM who discussed PrEP with their health care provider were significantly more likely than were black MSM to use PrEP (aPR = 1.2, 95% CI = 1.1–1.3). This disparity between white and black MSM persisted among those who had health insurance (aPR = 1.2, 95% CI = 1.1–1.3) and had a usual source of health care (aPR = 1.2, 95% CI = 1.1–1.3), which are typical barriers to accessing prescription medication. Disparities in PrEP use between white and black MSM existed in the south (aPR = 1.2, 95% CI = 1.1–1.4) and west (aPR = 1.3, 95% CI = 1.0–1.6) U.S. census regions, whereas disparities between white and Hispanic MSM existed only in the south (aPR = 1.2, 95% CI = 1.1–1.4).

* https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf.
https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview?s_cid=ht_endinghivinternet0002.
§ https://www.cdc.gov/hiv/risk/prep/index.html.
NHBS is cross-sectional biobehavioral surveillance system conducted in U.S. urban areas with high HIV prevalence. In 2017, MSM in 23 urban areas (Atlanta, Georgia; Baltimore, Maryland; Boston, Massachusetts; Chicago, Illinois; Dallas, Texas; Denver, Colorado; Detroit, Michigan; Houston, Texas; Los Angeles, California; Memphis, Tennessee; Miami, Florida; Nassau and Suffolk counties, New York; New Orleans, Louisiana; New York, New York; Newark, New Jersey; Philadelphia, Pennsylvania; Portland, Oregon; San Diego, California; San Francisco, California; San Juan, Puerto Rico; Seattle, Washington; Virginia Beach, Virginia; and Washington, DC) were recruited using venue-based sampling. Eligible participants (men who were born male and identified as male, reported having ever had oral or anal sex with another man, resided in the interview urban area, and were aged ≥18 years) completed standardized questionnaires in English or Spanish administered in person by trained interviewers. All participants were offered anonymous HIV testing and incentives for the interview and HIV test. The type of incentive (cash or gift card) and amount varied by urban area according to formative assessment and local policy. A typical incentive 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 within the past 6 months or a bacterial sexually transmitted infection (i.e., syphilis, gonorrhea, or chlamydia) diagnosed or reported within 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 in a year as a proxy for a nonmonogamous partner.
†† HIV testing was performed for participants who consented. Blood specimens were collected for rapid testing in the field or laboratory-based testing. A nonreactive rapid test result was considered negative. A reactive rapid test was confirmed with either a second rapid test in the field or supplemental laboratory-based testing, typically western blot or indirect immunofluorescence assay.
§§ Syphilis, gonorrhea, or chlamydia.
¶¶ 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 of getting HIV. Three steps of the HIV PrEP continuum of care were assessed by race/ethnicity, using the following questions: "Before today, have you ever heard of PrEP?" Respondents who answered "Yes" were asked "In the past 12 months, have you had a discussion with a health care provider about taking PrEP?" and "In the past 12 months, have you taken PrEP to reduce the risk of getting HIV?"

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