July 24, 2024

Beyond White and Gay  

PrEP has achieved substantial usage, but only among White gay and bisexual men. Even though the use of PrEP among Black and Latino people in the United States has doubled over the past five years, it still greatly lags that of their White counterparts.

Gay and Bisexual Men and New HIV cases

Similarly, new HIV transmission rates among White gay and bisexual men have declined while rates among Black and Latino men have remained stable and only modestly declined. Such inequity remains despite the efforts of a nationwide public health workforce and countless millions of dollars spent promoting and facilitating PrEP use among Black and Latino gay and bisexual men. With recent opinions in cases like Dobbs and Braidwood, these inequities are likely to grow.

According to the Centers for Disease Control and Prevention (CDC), gay and bisexual men account for 70 percent of new cases of HIV. White gay and bisexual men comprised 15 percent of the 34,800 people newly diagnosed with HIV in 2019, while the much smaller populations of their Black and Latino peers comprised a respective 26 percent and 23 percent of new cases.

More than a year after the approval of a long-acting injectable form of PrEP, cabotegravir, few are receiving it. Insurers have mostly refused to cover the expensive drug. Even after clinical trials found injectable PrEP superior to oral PrEP at preventing HIV, especially among Black gay men, cabotegravir’s potential will likely have little effect on these outcomes.

PrEP Has Not Yet Delivered

In cities where it has received a critical mass of popularity, PrEP has helped drive down HIV rates. But nationally, PrEP has failed to move the needle by much.

Approximately 814,000 gay and bisexual men in the U.S. are good PrEP candidates, the CDC estimates. Between 2017 and 2022, the number of people using PrEP at any point during each given year increased from 155,000 to 382,000. However, studies show that many people who start PrEP do not take it for long.

A growing body of research suggests emphasis should now be placed on upstream factors that influence health and the need for policy interventions to address those factors in addition to new clinical approaches and interventions aimed at modifying behavior.

Systemic Factors in the South

Many of the Black gay and bisexual men who are yet to be reached live in the South where less than half of the needs for health providers are met.

The South includes several systemic factors that conspire to make progress among this population uniquely challenging. Four of the six U.S. states with the lowest ratios of primary care provider to population are in the South. Furthermore, the South has a higher proportion of people living in poverty than other U.S. regions. Attending multiple health care visits for PrEP also requires more time away from work, which is harder for people living in poverty.

Low Capacity for Health Care

The low capacity for multiple health care visits for PrEP among Black and Latino people is exacerbated by multiple factors, including:

• Lack of proximity of PrEP providers.
• Lack of health insurance to pay for multiple visits.
• Unmet health care capacity.

Low HIV Risk Perception

In groups like Black gay and bisexual men who are at increased risk for HIV, studies indicate a low risk perception, even among those who later acquire HIV. Lack of identification of risk and communication with providers about risk are also cited as barriers to PrEP uptake among Black women and transwomen.

Current Strategies

The current pipeline of federal strategies primarily focus on improving implementation. These include HIV prevention communication, telemedicine and mobile health for PrEP, as well as using social networks and social media to increase awareness, with a particular focus on increasing PrEP use among cisgender heterosexual women.

Call for a Better Understanding

Whether new PrEP technologies, including long-acting injectables and other preventive medications will increase PrEP uptake remains to be seen. A better understanding of the barriers to retention in PrEP care for Black and Latino individuals, especially among women, is needed.

Broader questions also include how future policies and laws might affect health insurance, sexual health, reproductive health and health care access generally. Our collective efforts should focus not only on individual risks but more directly on systemic racism, implicit bias, cultural humility, stigma and gender discrimination as public health issues. Once our prevention scope has broadened, we then can do much more to increase awareness and better deploy intersectional strategies designed to address structural factors related to HIV risk and PrEP use.

Call for Collaboration

To significantly reduce disparities for PrEP, researchers must collaborate with community members to better identify and implement proven strategies that will address these ongoing needs for Black and Latino communities.

To reach the goals of the Ending the HIV Epidemic initiative, the state and federal policymakers, providers, communities, and health departments and academies must partner to fill the gaps that remain. Key research opportunities exist in evaluating PrEP uptake strategies tailored to women and to Black and Latino individuals living in nonurban areas.

I have been asked to speak on these issues in Portland later this month as an emissary of the Academy. It is important that we consider the effects of these structural and systemic challenges of HIV prevention on the patient-provider relationship. As a department, we are in the process of choosing our policy priorities and composing position statements where appropriate. We have chosen PrEP as one of these priorities. I’d like to invite each Academy member, regardless of their previous policy experience or expertise, to participate in this process starting at the end of summer. If you are interested in being a part of this endeavor, please email me at chauncey@aahivm.org.