Reaching Those Most at Risk for HIV Acquisition: Evaluating Racial/Ethnic Disparities in the Preexposure Prophylaxis Care Continuum in Baltimore City, Maryland

Abstract

Background: Reducing HIV incidence requires addressing persistent racial/ethnic disparities in HIV burden. Our goal was to evaluate preexposure prophylaxis (PrEP) delivery, overall and relative to community need, among 7 clinical sites participating in a health department-led demonstration project to increase PrEP in Baltimore city, MD.Methods: PrEP care continuum stages (screened, indicated, referred, linked, evaluated, prescribed) were examined among HIV-negative individuals receiving services at participating sites between September 30, 2015 and September 29, 2019. Community need was defined using information on new HIV diagnoses (2016)(2017)(2018). Differences in care continuum progression by demographics/priority population and comparison of demographic compositions between care continuum stages and new HIV diagnoses were examined using modified Poisson regression and x 2 tests, respectively.Results: Among 25,886 PrEP-screened individuals, the majority were non-Hispanic (NH) black (81.1%, n = 20,998), cisgender male (61.1%, n = 15,825), and heterosexual (86.7%, n = 22,452). Overall, 31.1% (n = 8063) were PrEP-indicated; among whom, 56.8% (n = 4578), 15.6% (n = 1250), 10.8% (n = 868), and 9.0% (n = 722) were PrEP-referred, linked, evaluated, and prescribed, respectively. Among 2870 men who have sex with men (MSM), 18.7% (n = 538) were PrEP-prescribed. Across all groups, the highest attrition was between PrEP-referred and PrEP-linked. NHblack race (vs. NH-white) was independently associated with lower likelihood of PrEP prescription (aPR, 0.89; 95% confidence interval, 0.81 to 0.98 controlling for age/gender). Relative to the demographic composition of new HIV diagnoses, fewer NH-blacks (80.2% vs. 54.3%) and more NH-whites (10.7% vs. 30.3%) and MSM were PrEP prescribed (55.2% vs. 74.5%).Conclusions: This project showed promise delivering PrEP referrals and prescriptions overall and to MSM. Substantial improvement is needed to improve linkage overall and to decrease disparities in PrEP prescriptions among NH-blacks. Future work should focus on addressing service gaps that hinder PrEP utilization.

Preexposure Prophylaxis to Prevent Acquisition of HIV

“…CDC data also showed disparities in PrEP use relative to indications for PrEP (PrEP coverage) by sex (lower in females than in males) and age (lower in persons aged 16 to 24 years than in those 25 years or older) . Limited data suggest that PrEP use is lower in transgender women than in men who have sex with men . These barriers and disparities need to be addressed to achieve the full benefit of PrEP.…”

Psychological distress and adherence to anti-retroviral therapy or pre-exposure prophylaxis regimens among Urban Black gay and bisexual men (MSM)

“…Eligibility for PrEP was based on clinical guidelines and local epidemiology and included all HIV negative MSM participants. 24 Psychological distress (main exposure) was assessed with a scale previously validated among minority MSM across three large U.S. cities which showed strong internal consistency (Cronbach's α = 0.83) in our study sample. 25 The scale measured prevalence of the following psychological symptoms in the past three months: (1) sleep disturbances, measured by how often the participant had difficulty sleeping, (2) anxiety, measured by how often the participant felt scared or panicky for no apparent reason, (3) suicidality, measured by how often the participant felt like taking their own life, (4) depression, measured by how often the participant felt sad or depressed, and (5) general health, measured by how often the participant felt sick, ill, or not well.…”

“…Eligibility for PrEP was based on clinical guidelines and local epidemiology and included all HIV negative MSM participants. 24…”

Racial disparities in access to reproductive health and fertility care in the United States

“…Disparities in preexposure prophylaxis (PrEP) access and uptake are recognized to underlie the disproportionate HIV-specific disease burden that is shouldered by the Black and Hispanic populations in the US, which notably worsened between 2010 and 2015 [23]. Several studies indicate that, compared to the White population, Blacks and/or Hispanics are significantly less likely to be aware or knowledgeable of PrEP [23,24], have discussed PrEP with a provider [23], be prescribed PrEP [25 ▪ ], or to have used PrEP [23,26 ▪ ]; and significantly more likely to discontinue PrEP [27]. Existing data underscore a need for targeted interventions to enhance awareness of infectivity and minimize acquisition of HPV and HIV infection among minority populations through adoption of effective preventive approaches.…”