HIV Preexposure Prophylaxis Awareness and Referral to Providers Among Hispanic/Latino Persons

United States, 2019

Shubha Rao, MPH; Mesfin S. Mulatu, PhD; Mingjing Xia, MS; Guoshen Wang, MS; Wei Song, PhD; Aba Essuon, PhD; Deesha Patel, MPH; Adanze Eke, MS; Emilio J. German, MSHSA

Disclosures

Morbidity and Mortality Weekly Report. 2021;70(40):1395-1400. 

In This Article

Abstract and Introduction

Introduction

Hispanic or Latino* (Hispanic) persons are disproportionately affected by HIV in the United States. In 2019, Hispanic persons accounted for 18% of the U.S. population, but for 29% of new diagnoses of HIV infection.[1] The Ending the HIV Epidemic in the U.S. (EHE) initiative aims to reduce new HIV infections by 90% by 2030.[2] Preexposure prophylaxis (PrEP), medication taken to prevent acquisition of HIV, is an effective strategy for preventing HIV infection. To examine PrEP awareness and referral to providers among Hispanic persons, CDC analyzed 2019 National HIV Prevention Program Monitoring and Evaluation HIV testing data. Approximately one quarter (27%) of Hispanic persons tested for HIV at CDC-funded sites (n = 310,954) were aware of PrEP, and 22% of those who received a negative HIV test result and were eligible for referral (111,644) were referred to PrEP providers. PrEP awareness and referrals among Hispanic persons were lower compared with those among non-Hispanic White persons. Among Hispanic persons, significant differences were found in PrEP awareness and referrals by age, gender, race, population group, geographic region, and test setting. HIV testing programs can expand PrEP services for Hispanic persons by implementing culturally and linguistically appropriate strategies that routinize PrEP education and referral, collaborating with health care and other providers, and addressing social and structural barriers.

CDC analyzed 2019 National HIV Prevention Program Monitoring and Evaluation HIV testing data submitted by 60 CDC-funded state, local, and territorial health departments§ and 29 directly funded community-based organizations to assess measures of PrEP awareness and referral to a PrEP provider.** Persons whose HIV status is negative are eligible for PrEP referral when they meet the clinical criteria for PrEP prescription based on CDC guidelines or local protocols. PrEP awareness among persons tested for HIV infection was defined by an affirmative response documented by HIV test providers to the question, "Has the client ever heard of PrEP?" Similarly, PrEP referral among persons eligible for referral was defined by an affirmative response documented by HIV test providers to the question, "Was the client given a referral to a PrEP provider?" PrEP awareness and referrals among Hispanic persons were compared with those of persons of other racial and ethnic groups. PrEP measures among Hispanic persons were also compared by age, gender, race,†† ethnicity,§§ test setting, ¶¶ U.S. Census region,*** and population groups defined by transmission risk.††† Robust Poisson regression was used to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs). This activity was reviewed and approved by CDC and conducted consistent with applicable federal law and CDC policy.§§§

During 2019 in the United States, 2,341,342 CDC-funded HIV tests were conducted. These included 546,337 (23.3%) tests conducted among Hispanic persons, 919,066 (39.3%) among non-Hispanic Black/African American (Black) persons, 658,496 (28.1%) among non-Hispanic White (White) persons, and 217,443 (9.3%) among persons of other or unspecified race. Among all tested persons with PrEP-related data, PrEP awareness was slightly higher among Hispanic persons (27.4%) than among Black persons (26.2%; PR = 1.05; 95% CI = 1.04–1.06) but lower than that among White persons (31.4%; PR = 0.87; 95% CI = 0.87–0.88) and those of other racial or ethnic groups (42.1%; PR = 0.65; 95% CI = 0.64–0.66) (Figure).

Figure.

Preexposure prophylaxis awareness and referral to preexposure prophylaxis providers, by race and ethnicity* — United States, 2019†,§
Abbreviation: PrEP = preexposure prophylaxis.
*Black, White, and persons of other races were non-Hispanic; Hispanic persons could be of any race.
Valid HIV tests for this analysis include tests for which a test result (i.e., positive or negative) was known and had a nonmissing value for PrEP awareness and referral.
§PrEP awareness among persons tested for HIV infection was defined by an affirmative response documented by HIV test providers to the question, "Has the client ever heard of PrEP?" PrEP referral among persons eligible for referral was defined by an affirmative response documented by HIV test providers to the question, "Was the client given a referral to a PrEP provider?" This analysis excluded HIV tests with missing values on PrEP awareness and referral to a PrEP provider.

Among Hispanic persons, awareness was higher among persons aged 25–49 years (29.9%; PR = 1.07) and lower among those aged ≥50 years (17.0%; PR = 0.60) compared with those aged 13–24 years (28.1%) (Table 1). By gender, compared with females, 14.5% of whom were aware of PrEP, awareness was highest among transgender persons (68.6%; PR = 4.74) followed by males (36.6%; PR = 2.53). Awareness was higher among Black Hispanic persons (39.3%; PR = 1.91) and persons of other races (39.3%; PR = 1.91) than among White Hispanic persons (20.6%). Compared with heterosexual Hispanic females (awareness = 17.5%), PrEP awareness was higher among gay, bisexual, and other men who have sex with men (MSM) (63.5%; PR = 3.62), persons who inject drugs (28.9%; PR = 1.65), and heterosexual males (21.5%; PR = 1.22). Awareness was higher among persons tested in non–health care settings (35.4%; PR = 1.95) than among those tested in health care settings (18.1%). By U.S. Census region, PrEP awareness was lower among Hispanic persons tested in the West (49.1%; PR = 0.87), Midwest (30.1%; PR = 0.54), South (13.4%; PR = 0.24), and U.S. territories (12.9%; PR = 0.23) than among those tested in the Northeast (56.2%).

Overall, referral to a PrEP provider was higher among Hispanic persons (22.0%) compared with non-Hispanic Black persons (20.8%; PR = 1.06; 95% CI = 1.04–1.07) but lower when compared with non-Hispanic White persons (25.9%; PR = 0.85; 95% CI = 0.84–0.86) and those of other racial/ethnic groups (25.8%; PR = 0.85; 95% CI= 0.83–0.87) (Figure).

Among Hispanic persons eligible for referral to a PrEP provider, PrEP referral was higher among Hispanic persons aged 25–49 years (22.8%; PR = 1.05) and lower among those aged ≥50 years (16.6%; PR = 0.77) compared with those aged 13–24 years (21.7%) (Table 2). By gender, referral was higher among transgender persons (30.3%; PR = 2.04) and males (25.7%; PR = 1.73) than among females (14.8%). PrEP referral was lower among Black Hispanic persons (13.4%; PR = 0.55) and Hispanic persons of other races (21.6%; PR = 0.89) than among White Hispanic persons (24.3%). PrEP referral was higher among Hispanic MSM (39.5%; PR = 2.57) and persons who inject drugs (17.2%; PR = 1.12) but lower among heterosexual males (11.7%; PR = 0.76) than heterosexual females (15.4%). By test setting, PrEP referral was lower among persons tested in non–health care settings (20.4%; PR = 0.83) than among those tested in health care settings (24.6%). By U.S. Census region, PrEP referral was higher among Hispanic persons tested in the Midwest (32.9%; PR = 2.14), South (26.9%; PR = 1.75), and West (17.8%; PR = 1.16) and lower among those tested in U.S. territories (13.4%; PR = 0.87) compared with persons tested in the Northeast (15.4%).

*Hispanic persons can be of any race.
https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf
§Fifty states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and seven Metropolitan Statistical Areas or specified Metropolitan Divisions: Baltimore, Chicago, Houston, Los Angeles County, New York City, Philadelphia, and San Francisco.
PrEP awareness was assessed by HIV test providers documenting a response to the question, "Has the client ever heard of PrEP (PreExposure Prophylaxis)?" The PrEP awareness question was required from all persons testing for HIV although the response could have been collected before or after the test was performed.
**Referral to PrEP providers was assessed by HIV test providers documenting a response to the question, "Was the client given a referral to a PrEP provider?" Referral was provided if the person testing negative for HIV infection met the appropriate clinical criteria for using PrEP or was determined to be eligible for a PrEP referral based on CDC guidelines or local protocol. Referral to providers in this report might include passive referral (e.g., client is provided information about the PrEP provider) as well as active referral (e.g., client is assisted with contacting and making an appointment with the PrEP provider).
††Race refers to the client's self-reported classification or classifications of the biologic heritage with which they most closely identify. For this report, Hispanic persons are stratified into three race groups: Black or African American (Black), White, and other, which includes American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander persons, or those with more than one race.
§§Ethnicity refers to the client's self-report of whether they are of Hispanic or Latino origin.
¶¶For each CDC-funded test, test setting is the location where the test was administered. Health care settings are clinical settings in which both medical diagnostic and treatment services were provided (e.g., primary care clinics, community health centers, emergency departments). Non–health care settings are nonclinical settings in which neither medical diagnostic nor treatment services are provided (e.g., schools or educational facilities, faith-based facilities, and field testing sites).
***State and local health department jurisdictions were categorized into the four U.S. Census regions (Northeast, Midwest, South, and West) (https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf). Puerto Rico and the U.S. Virgin Islands were grouped into the category "U.S. territories."
†††Data on behavioral risk characteristics were reported for the last 5 years before the HIV test. Men who have sex with men (MSM) includes males who reported male-to-male sexual contact and represents gay, bisexual, and other MSM; and males who reported both male-to-male sexual contact and injection drug use. Persons who inject drugs include persons who reported injection drug use. Heterosexual males include males who reported only heterosexual contact with a female. Heterosexual females include females who reported only heterosexual contact with a male. Others include transgender persons who inject drugs, transgender persons, women who have sex with women, men or women who have sex with transgender persons, and persons with no history of sexual contact or injection drug use.
§§§45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

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