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Disparities in PrEP

Medically Reviewed by Jonathan E. Kaplan, MD on April 06, 2022

In 1981, the first case of what would become known as AIDS was reported in the United States. At the time, there was a lot of fear and misunderstanding about the condition. Although our understanding of AIDS and HIV, the virus that causes AIDS, has come a long way, we still have a long way to go.

Today, we know how AIDS is transmitted. Better treatments and prevention mean AIDS is no longer a death sentence for many people. The development of PrEP, or pre-exposure prophylaxis, has been a key part of making this happen. If you’re at risk for HIV, this daily prescription medicine is highly effective in preventing the virus. In fact, new HIV infections fell 8% from 2015 to 2019 due to PrEP and increased testing and treatment.

Unfortunately, studies show that members of marginalized communities often find it harder to gain access to proper medical care. Because of this, many people who are at high risk for HIV aren’t receiving this treatment.

Who Can Take PrEP?

PrEP is for you if you don’t have HIV but are at high risk for HIV. You’re at high risk if you’ve had anal or vaginal sex in the last 6 months and have a sexual partner with HIV. You’re also at high risk if you don’t always use a condom or if you have been diagnosed with a sexually transmitted disease in the past 6 months. PrEP is also recommended for people who:

  • Inject drugs
  • Share needles or other tools to inject drugs
  • Have an injection partner with HIV

If PrEP is right for you, your doctor can prescribe it. You can also get a prescription at a community or sexual health clinic, or a nonprofit or government health clinic. If you don’t have prescription coverage through insurance, a program called Ready, Set, PrEP can help with free medication.

Low PrEP Use Among Those at Highest Risk

Unfortunately, those who can benefit the most from PrEP are prescribed it the least. Black people and Hispanic or Latino people make up the majority of people for whom PrEP is recommended. But they have the lowest rates of PrEP use when compared with all other racial or ethnic groups. Only 9% of Black people and 16% of Hispanic or Latino people who would benefit from PrEP received a prescription in 2020.

Young people who are at risk and could use this medication aren’t getting it either. In 2020, only about 16% of at-risk 16-24-year-olds were prescribed PrEP.

Men fare better in PrEP use than women. In 2020, only 10% of at-risk women used PrEP. Men had a rate three times as high. This is a big concern, since cisgender women (those who identify with the gender they were assigned at birth) made up 19% of new HIV diagnoses in 2019.

Many Reasons Why People Don’t Use PrEP

The reasons why someone may not take PrEP are as varied as the people themselves. For example, you may be unaware of it. Research from Johns Hopkins showed that only 4 in 10 HIV-positive gay and bisexual men in the Baltimore area were aware that PrEP reduced their risk of HIV. This includes men who had recently seen their doctors. A later study showed that although more people from all racial and ethnic groups were aware of PrEP, Black or Hispanic gay men discussed it less with their doctors or used it within the past year compared to white gay men.

There are many reasons why women may not be taking PrEP. Some may believe they aren’t at high risk for HIV. Others may simply be unaware. In one study of almost 1,500 cisgender women seeking services at a sexual health clinic, just one-third of them were aware of PrEP. But there was about a 60% awareness of PrEP among gay men who visited the clinic during the study period. Race and ethnicity were involved too. Slightly more than 20% of white women were aware of PrEP compared to 14% of Black women and 11% of Hispanic or Latina women.

Stigma also plays a huge role. Even today, HIV stigma remains a huge issue for many people. Studies show that PrEP users must often deal with being stereotyped as being irresponsible and as having too many sexual partners.

This stigma can affect physical health by causing people to not want to be tested. It could also make it tougher to stick with treatment – even preventive treatment like PrEP.

Stigma can also affect how you and your doctor talk to each other. Younger people may find it hard to speak frankly about sex out of fear of “coming out” or being judged. Stigma even affects PrEP, as some people think it may lead to risky sex. Doctors themselves commonly get little training that covers sexuality and how to talk to their patients about it.

A Combination of Efforts

There is no single fix to improving PrEP use among those who would benefit. Overcoming issues like poverty, homelessness, unequal access to health care, and stigma requires many different approaches.

Racism is an issue when it comes to unequal access. The CDC recently declared racism a public health threat. It is working to address racism as one of the main reasons behind racial and ethnic health disparities in many aspects of health care, including HIV prevention and care.

Due to CDC efforts, PrEP is now provided with no copay for nearly all people with commercial insurance and many people with public insurance. And the Ready, Set, PrEP program offers medications free of charge to those who qualify. The CDC is working closely with community-based organizations to increase referrals for PrEP among Black people, Hispanic or Latino people, gay and bisexual men, transgender women, and people who inject drugs.

The CDC has also recently recommended that providers tell all sexually active adults and adolescents about PrEP. They also suggest that after briefly asking about sexual history, that a provider prescribe PrEP to anyone who requests it, even if that person did not talk about high-risk HIV behaviors. The hope is that these efforts will help fight stigma and increase PrEP usage.

Nonprofits are also helping to get the message out. For example, the Black AIDS Institute has developed a PrEP tool kit created by Black women for Black women. Organizations can use this peer-to-peer approach to tailor their approach to reaching Black women.

Technology is also playing a role. Electronic consultations with specialists and mobile apps that allow PrEP prescriptions without an in-person visit are just a few tech innovations that show promise in helping to make PrEP more accessible to everyone who needs it.

Show Sources

SOURCES:

Kaiser Family Foundation: “The HIV/AIDS Epidemic in the United States: The Basics.”

CDC: “PrEP, Pre-Exposure Prophylaxis,” “PrEP for HIV Prevention in the U.S.,” “Racial/Ethnic Disparities in HIV Preexposure Prophylaxis Among Men Who Have Sex with Men — 23 Urban Areas, 2017,” “Morbidity and Mortality Weekly Report – September 20, 2019,” “Dear Colleague Message: Updated PrEP Guidelines.”

National Institutes of Health: “Pre-Exposure Prophylaxis (PrEP).”

HIV.gov: “Ready, Set, PrEP Expands Access to HIV Prevention Medications.”

Johns Hopkins Bloomberg School of Public Health: “Most Gay Men Are Not Aware Of Treatment To Protect Them From HIV.”

San Francisco Aids Coalition: “Low PrEP awareness and use among cis women seeking STI Services.”

Journal of Acquired Immune Deficiency Syndrome: “Brief Report: Pre-exposure Prophylaxis Awareness and Use Among Cisgender Women at a Sexually Transmitted Disease Clinic.”

Current HIV/AIDS Reports: “Understanding, Contextualizing, and Addressing PrEP Stigma to Enhance PrEP Implementation”, “A Review of Telehealth Innovations for HIV Pre-Exposure Prophylaxis (PrEP).”

Mount Sinai Adolescent Health Care: “5 Barriers Teens Face to Accessing PrEP.”

National Center for HIV, Viral Hepatitis, STD, and TB Prevention: “PrEP for HIV Prevention in the U.S.”

Black AIDS Institute: “Black Women and PrEP.”

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