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"Critical Barrier" Between PrEP Interest and Uptake in Young Black MSM
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Conference on Retroviruses and Opportunistic Infections (CROI), February 13-16, 2017, Seattle
Mark Mascolini
Among 116 young black men who have sex with men (MSM) in Atlanta interested in preexposure prophylaxis (PrEP), only 63 (54%) started PrEP and 52 (45%) remained on PrEP throughout follow-up [1].
The CDC recommends daily tenofovir/emtricitabine (TDF/FTC) PrEP for sexually active MSM and other high-risk groups [2]. MSM continue to account for most new HIV infections in the United States, and HIV incidence is particularly high among young black MSM. In Atlanta, noted Emory University researchers who conducted the new study [1], HIV incidence stands at 6.5% yearly in black MSM versus 1.7% yearly in white MSM.
The investigators stress that HIV prevention programs are struggling to include PrEP in prevention efforts because of the "intensive resources required for delivery." They maintain that "there is an ethical obligation to ensure that young black MSM have access to the best possible HIV prevention package, which includes PrEP."
The ele[men]t PrEP Study is an ongoing observational study of substance use and HIV risk in HIV-negative black MSM 16 to 29 years old in Atlanta. Researchers recruit men from the community regardless of initial PrEP awareness or interest, and they offer all participants PrEP regardless of HIV risk behavior. The investigators gauged PrEP uptake with unadjusted prevalence ratios; they used Kaplan-Meier analysis to assess time to PrEP interest, initiation visit, and PrEP start.
Among 184 men eligible for PrEP at enrollment, 18 men had no interest in starting and 50 planned to discuss PrEP at their next study visit. Of the remaining 116 men interested in starting PrEP, 63 (54%) did start and 53 (46%) had yet to attend their PrEP-initiation visit. Among the 63 PrEP starters, 11 (17%) stopped PrEP and 52 (83%) continued. Thus of 184 young black MSM eligible for PrEP and 116 interested in PrEP, only 28% and 49% were on PrEP at the end of follow-up. Median time between entering the program and a PrEP-initiation visit was 16 weeks, and median time to starting PrEP was 4 weeks after that.
Among the 11 men who stopped PrEP, 8 voluntarily withdrew, most often because they decided they had a low HIV risk. Three men stopped PrEP because they became infected with HIV, though none of these 3 were taking PrEP at the time of their HIV diagnosis. Overall, 5 men in the program picked up HIV through 95.3 person-years of follow-up to yield an annual HIV incidence of 5.3%.
Among the 184 young black MSM eligible for PrEP, 53% had heard of PrEP before enrollment, 76% had condomless anal sex in the past 6 months, 25% had a sexually transmitted infection (STI) in the past 12 months, and 59% had health insurance. Almost half of these men, 45%, had an annual income below $20,000, though 70% had at least some college education. Most men, 58%, were 24 or older.
Starting PrEP was less likely in men younger than 24 years old (33% versus 67%, unadjusted prevalence ratio [PR] 0.69), in men without some college education (25% versus 75%, PR 0.80), in men with an income below $20,000 (43% versus 57%, PR 0.92), and in men without health insurance (46% versus 54%, PR 0.83). Starting PrEP was more likely in men who identified themselves as homosexual rather than bisexual or other (84% versus 16%, PR 1.52), in men who had condomless anal sex in the past 6 months (83% versus 17%, PR 1.53), in men who had heard about PrEP before entering the program (60% versus 40%, PR 1.36), and in men without an STI in the past 12 months (67% versus 33%, PR 1.50).
The researchers conclude that "PrEP uptake among young black MSM was suboptimal and there seems to be a critical barrier between PrEP interest and uptake." They believe PrEP implementation is feasible in observational studies, "but additional delivery efforts may be required."
References
1. Rolle CPM, Siegler AS, Sanchez T, et al. Challenges of translating PrEP interest into uptake among young black MSM in Atlanta. Conference on Retroviruses and Opportunistic Infections (CROI), February 13-16, 2017, Seattle. Abstract 90.
2. Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States--2014. https://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf
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