Growth in Proportion and Disparities of HIV PrEP Use Among Key Populations Identified in the United States National Goals

Systematic Review and Meta-Analysis of Published Surveys

Emiko Kamitani, PhD; Wayne D. Johnson, PhD; Megan E. Wichser, MPH; Adebukola H. Adegbite, MPH; Mary M. Mullins, MSLS; Theresa Ann Sipe, PhD

Disclosures

J Acquir Immune Defic Syndr. 2020;84(4):379-386. 

In This Article

Abstract and Introduction

Abstract

Background: Pre-exposure prophylaxis (PrEP) use among populations most vulnerable to HIV as identified in the national HIV prevention goals is not fully known. This systematic review assessed trends of lifetime self-reported PrEP use and disparities among key populations.

Methods: We used the CDC HIV/AIDS Prevention Research Synthesis cumulative database of electronic and manual searches in MEDLINE, CINAHL, EMBASE, and PsycINFO from 2000 to 2019 to identify English-language primary studies reporting PrEP use. Two reviewers independently screened citations, extracted data, and assessed the risk of bias with the modified Newcastle–Ottawa Scale. We estimated pooled proportions and crude/adjusted odds ratio.

Results: We identified 95 eligible studies including 95,854 US-based survey respondents. A few studies (6.3%) focused on persons who inject drugs. In 2015–2017, men who have sex with men (MSM) had highest proportion of individuals who used PrEP over their lifetime [13.9% (95% confidence interval: 8.8 to 21.1), k (number of surveys) = 49] followed by Hispanic/Latinos [11.5 (7.1 to 18.1), 12], transgender women [11.2 (5.8 to 20.6), 5], and blacks [9.9 (8.3 to 11.8), 18]. Odds of PrEP use increased by 34%/year [odds ratio = 1.34/year (95% confidence interval: 1.09 to 1.64)] and significantly increased over time among MSM [1.53/year (1.21–1.93)] and blacks [1.44 (1.13–1.83)]. People in the Southern United States [9.9 (4.7–19.7), 8] and youth [7.3 (4.7–11.2), 8] had lower rates and did not demonstrate growth [0.94 (0.29–3.18); 0.82 (0.43–1.55)]. Odds of reporting lifetime PrEP use was twice [2.07 (1.27–3.38)] as great among MSM than non-MSM.

Conclusions: Proportions of PrEP use in published surveys have been growing, but remain low for people in the Southern United States and youth, and understudied in persons who inject drugs. Limitations include few studies in certain years, whereas strengths include a large number of respondents. Culturally tailored approaches targeting vulnerable populations are essential in increasing PrEP use to reduce disparities in HIV acquisition.

Introduction

Pre-exposure prophylaxis (PrEP) has been shown to reduce HIV transmission in clinical trials and community-based ("real-world") studies.[1–4] The US Food and Drug Administration (FDA) licensed tenofovir disoproxil fumarate (TDF)/emtricitabine for PrEP in 2012 and emtricitabine/tenofovir alafenamide in 2019. The US Centers for Disease Control and Prevention (CDC) released the first PrEP guideline in 2014. Use of PrEP has been significantly associated with decline in new HIV diagnoses in the United States.[5]

A list of updated national HIV goals from the US National HIV Strategy identified 7 key populations and geographic areas that are vulnerable to HIV infection in the United States: gay, bisexual, and other men who have sex with men of all races and ethnicities (collectively referred to as MSM); black or African American women and men (hereafter referred to as blacks); Hispanic or Latino men and women (hereafter referred to as Hispanic/Latinos); persons who inject drugs (PWID); youth aged 13–24 years; people in the Southern United States; and transgender women.[6,7] About 66% of US HIV infections diagnosed in 2017 were among MSM, 43% among blacks, 26% among Hispanic/Latinos, 7% among PWID, 21% among youth, and 52% among people in the Southern United States.[8] Although surveillance data do not include information on transgender women (which may be included in the MSM group), an estimated 1% of new HIV diagnoses were among this population.[9] Because members of these key populations are at a highest risk of HIV infection, they may be prioritized candidates for PrEP.

A recent assessment of US retail pharmacies estimated that 148,147 unique individuals have taken TDF/emtricitabine for PrEP as of September 2017.[10] This number does not include clients in closed health care systems with their own pharmacies that are not included in retail pharmacy data. Also, because of the cost of antiretroviral medications (ARVs), lack of awareness that ARV can legally be prescribed for use by HIV-seronegative persons, or the hassle and time it takes to get a prescription, some HIV-seronegative persons have taken ARVs to prevent HIV without a prescription or supervision by healthcare providers.[11] A recent meta-analysis found that by 2016, about 1 in 6 people who responded to the US surveys self-reported using PrEP (although this was not confirmed by medical record).[12] However, it is unclear how widely PrEP has been used within key populations identified in the US national HIV goals and whether PrEP has reached populations with the highest need. The purpose of this meta-analysis was to (1) assess trends in PrEP use by estimating the proportion of lifetime PrEP use across years and the growth pre-CDC/post-CDC clinical guideline released in 2014 and (2) assess PrEP use disparities among key populations and geographic areas identified in the US national HIV goals.

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