Combating an Epidemic Takes Prep Work

HIV is preventable disease but continues to pose a public health threat with nearly 40,000 new infections yearly in the U.S. Its economic burden is approximately $36.4 billion annually for direct medical care and lost productivity. To combat this epidemic, prevention strategies such as Pre-Exposure Prophylaxis (PrEP) have been developed to reduce the risk of HIV transmission but have received little uptake among the highest risk populations.  

A recent article identified disparities in demographic and behavioral factors that influence PrEP uptake. The authors examined the perceived need, eligibility and use of PrEp among transgender and men who have sex with men (MSM) individuals that received sexually transmitted disease (STD) testing at a Los Angeles area LGBT clinic. They found that 70% of those surveyed were eligible for PrEP, 37% reported a perceived need, yet only 10% were actively using PrEP. Use of sex drugs, recent STDs, older age, and higher education were associated with higher use of PrEP. Among those surveyed, the greatest perceived need was among young Black and Latino individuals even though these groups also had the lowest reported PrEP use. 

The findings parallel the state of HIV in America, with half of all new infections occurring among Black and Latino MSM living in the South. Yet these groups represent fewer than 5% of PrEP users. Although this article highlighted disparities in PrEP usage at the individual level, there are numerous public policy level implications. PrEP is estimated to cost $10,000 per year –including frequent laboratory testing, regular appointments, and medication. Despite the price, PrEP is cost-effective among high risk groups. 

HIV continues to affect the most economically disenfranchised and uninsured populations in the South. With the majority Southern states not expanding Medicaid, policymakers have left the population most at need without the financial resources to access this form of prevention. Insurance coverage is significantly associated with PrEP use; states that expanded Medicaid have higher PrEP use and more PrEP users than new HIV infections, compared to states that have not expanded Medicaid. 

PrEP could help end the HIV epidemic, but policies to make it affordable and accessible, such as Medicaid expansion, are needed. Additionally, policies incentivizing local health departments and STD clinics to include PrEP discussions will increase awareness and ensure that at risk individuals are adequately informed.

This Health Policy Journal Club review is a collaboration between Policy Prescriptions® and the Satcher Health Leadership Institute. It is written by Mirnouve Domond. She is a Health Policy Leadership Fellow.

Abstract

OBJECTIVES: To characterize uptake of HIV preexposure prophylaxis (PrEP) in a community setting and to identify disparities in PrEP use by demographic and behavioral factors associated with increased HIV risk.

METHODS: We conducted a cross-sectional study of 19?587 men who have sex with men and transgender people visiting a Los Angeles, California, clinic specializing in lesbian, gay, bisexual, and transgender care between August 2015 and February 2018 by using clinical care data.

RESULTS: Seventy percent of patients met PrEP eligibility criteria, while 10% reported PrEP use. Using sex drugs, reporting both condomless anal intercourse and recent sexually transmitted infection, older age, and higher education level were associated with higher odds of PrEP use given eligibility. Latino or Asian race/ethnicity and bisexual orientation were associated with lower odds of PrEP use given eligibility. Higher odds of perceived need were associated with demographic risk factors but PrEP use was not similarly elevated.

CONCLUSIONS: Discrepancies between PrEP eligibility, perceived need, and use reveal opportunities to improve PrEP delivery in community settings. Public Health Implications. Efforts are needed to facilitate PrEP uptake in populations with highest HIV incidence.

PMID: 30138062

Shover, CL, et al. Am J Public Health. 2018; 108 (10): 1408-1417.