Why PrEP Access Is Missing the Mark (And What Can Be Done to Close the Gaps)
Boston University researchers are looking at ways to ensure that PrEP, an HIV prevention medication, is offered to those who need it most.
By Thalia Plata
Pride Month offers an opportunity to celebrate the identities and history of LGBTQIA+ people and also provides an opportunity to discuss health disparities affecting members of the community.
July 16th marks a decade since the first HIV prevention medication was approved by the FDA. Pre-exposure prophylaxis, commonly called PrEP, can reduce the chance of contracting HIV from sex or injection drug use. When taken as prescribed, PrEP is highly effective for preventing HIV.
The use of PrEP has become more commonplace in recent years. Preliminary CDC data shows that “in 2020, about 25% of the 1.2 million people for whom PrEP is recommended were prescribed it, compared to only about 3% in 2015.” While PrEP can be taken by anyone regardless of sexual orientation or gender identity, HIV continues to affect some groups disproportionately.
According to the CDC’s HIV Surveillance Report released in May, gay, bisexual, and other men who reported male-to-male sexual contact are the population most affected by HIV. The report also found that racial and ethnic differences in diagnosis and treatment persist, and cites “racism, HIV stigma, discrimination, homophobia, poverty, and barriers to health care” as contributing factors.
Here are some ways researchers at Boston University are tackling these problems and offering solutions to increase access to PrEP for vulnerable populations.
Closing the Racial Gaps
Dr. Julia Raifman, an assistant professor at BU’s School of Public Health, conducts research on how health and social policies shape population health and health disparities. One of her research goals is to reduce “the disproportionate burden of HIV and other health disparities among sexual minorities.” Her work on HIV is focused on how structural stigma and structural racism shape disparities in the burden of HIV, including the implementation of PrEP.
In a paper published in AIDS and Behavior and one of the first studies to demonstrate significant ethnic and racial disparities in PrEP awareness among men who have sex with men, Raifman and her team looked at data among a group of male patients at a Rhode Island STD Clinic who reported having sex with men.
They found that PrEP awareness among non-Hispanic Black men was initially lower, but caught up with PrEP awareness among non-Hispanic white men by 2016. PrEP awareness among Hispanic men remained consistently lower than PrEP awareness among non-Hispanic white men.
The team suggests that the disparities might be linked to “experiences of provider discrimination based on race or ethnicity” and language barriers among Hispanic patients. Younger men are also less likely to be aware of PrEP since they might not be socially connected to other PrEP users and are unlikely to learn about HIV prevention in most health education courses.
The research team noted that there remains a need for culturally sensitive interventions and recommends that healthcare providers share Spanish-language materials and resources. With new strides being made in HIV prevention, the team stresses the importance of sharing new information through social marketing campaigns and by healthcare providers.
The Role of Pediatricians and PrEP in Sex Education
Despite PrEP being available for almost ten years, according to the CDC, people aged 13 to 34 accounted for more than half of new HIV diagnoses in 2020, which raises questions as to the education surrounding PrEP.
Dr. Katherine Hsu is an associate professor of pediatrics in adolescent medicine at BU’s School of Medicine. One area of her research focuses on sexually transmitted diseases and syndromes in adolescents and young adults. She also serves as medical director for the Division of STD Prevention & HIV/AIDS Surveillance as a part of the Bureau of Infectious Disease and Laboratory Sciences at the Massachusetts Department of Public Health.
Last December, Hsu and Natella Yurievna Rakhmanina from The George Washington University published a clinical report in Pediatrics titled The Pediatrician’s Role in HIV Testing and Pre- and Post-exposure HIV Prophylaxis. Together, they address “consent, confidentiality, and coverage issues that pediatricians face in promoting routine HIV testing and HIV prophylaxis for their patients.”
According to data from the CDC cited in their report, in 2018, HIV infection was undiagnosed in an estimated 45% of 13- to 24-year-olds living with HIV. Youth with HIV infection are also the least likely of any age group to receive HIV treatment in a timely manner. Youth at high risk for HIV often have the lowest PrEP awareness and uptake rates.
Hsu and her collaborator urge pediatricians and primary care doctors to establish an open environment to discuss HIV testing and post-exposure prophylaxis (PEP), and preexposure prophylaxis (PrEP) in youth at risk for HIV infection.
Hsu and her coauthor provide recommendations for steps that pediatricians can take to educate their young patients that are at higher risk of contracting HIV. Recommendations such as “routine HIV screening be[ing] offered to all youth 15 years or older, at least once, in health care settings” and that “after initial screening, youth at increased risk, including sexually active youth, should be rescreened at least annually, potentially as frequently as every 3 to 6 months if at high risk.”
The authors also note that HIV risk factors and PrEP should be covered under general health and sex education for all youth. They state, “By contextualizing HIV risk discussions within comprehensive sexuality education… youth may have a greater comprehension of the problem and their own risk and be willing to seek care from pediatricians.”
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