‘PrEP Has Potential, but Only If People Take It’.

In the United States, men who have sex with men (MSM) have a one-in-six chance of contracting HIV in their lifetimes. This could change through pre-exposure prophylaxis (PrEP), a daily pill that reduces a person’s HIV risk by 99 percent. But PrEP uptake has been slow since the pill’s Food and Drug Administration (FDA) approval in 2012, and as of 2017 only an estimated 10 percent of people at high risk for HIV were taking PrEP.

Black and Hispanic MSM are two-to-five times more likely to contract HIV than white MSM. But they are also less likely to know about PrEP—and, as PrEP awareness has gone up in general, the gap has persisted.

That’s according to two new studies, one from the US Centers for Disease Control and Prevention (CDC) and the other led by a School of Public Health researcher.

“PrEP has the potential to dramatically reduce the burden of HIV, but only if people take it, and they can’t take it unless they’re aware of it,” says Julia Raifman, assistant professor of health law, policy & management, and lead author of the latter study, published in the journal AIDS and Behavior.

“It’s critically important that we communicate about healthcare innovations that prevent or treat HIV (and other diseases) through culturally competent approaches that reach those most at risk,” she says. “Otherwise, new innovations may only exacerbate existing racial and ethnic disparities.”

Raifman discussed the two studies, the reasons for the continued racial/ethnic gap in PrEP awareness, and what needs to change.

What did your study look at, and what did you find?

We looked at trends in PrEP awareness by race and ethnicity among men who have sex with men when they came for their first visits at an STD clinic in Rhode Island between 2012 and 2016.

We found that black and Latino men had lower levels of PrEP awareness relative to white men on average between 2012 and 2016. But PrEP awareness among black men converged with that of white men by 2015, while PrEP awareness remained lower among Latino men.

How do these findings compare to other recent research, such as the new CDC study?

Our findings are largely consistent with other findings that racial and ethnic disparities persist when it comes to HIV, and when it comes to PrEP to prevent HIV.

While we saw racial disparities in PrEP awareness diminish over time in the Rhode Island STD clinic population, national data indicate racial disparities in PrEP awareness, use, and adherence are persisting over time. For instance, the new CDC study shows that black men who have sex with men were still less likely to know about PrEP than white MSM in 2017.

The STD clinic we studied has made a concerted effort to educate the community about PrEP, which may have reduced racial disparities in the clinic population in a way that is not more broadly representative. Continually lower levels of PrEP awareness among Latino men also points to the importance of Spanish-language materials for communicating about PrEP at the Rhode Island clinic and nationwide.

What do you see as the likely cause(s) of these racial/ethnic disparities?

There are several structural factors that have shaped disparities that characterize the burden of HIV in the United States and that shape continued disparities with new innovations like PrEP.

Forces such as homophobia, racism, and xenophobia have shaped deeply entrenched inequities in education, wealth and income, and access to health care. Furthermore, there is evidence that homophobia and racism shape provider attitudes about providing PrEP.

What solutions do you see for closing this gap in PrEP knowledge—and by extension, PrEP use?

Structural changes to taxation, education, and health systems that address fundamental inequities in education, wealth and income, and access to health care would likely do the most to reduce disparities relating to HIV, PrEP—and several other diseases and treatments.

More targeted efforts could include provider education about PrEP and trainings addressing implicit bias, as well as PrEP communications campaigns targeting communities most at risk.

More PrEP awareness is the first step toward more people taking PrEP. If enough people took it, it could reduce the proportion of people living with HIV in whole communities and populations. And it could have the greatest impact among communities with the greatest burden of HIV: black and Latino MSM.

—Michelle Samuels