While PrEP Use Has Skyrocketed Among Urban MSM, Geographic Access Lags Elsewhere

As the CDC released data showing an approximate 500% increase in the use of pre-exposure prophylaxis (PrEP) for HIV prevention among men who have sex with men (MSM) in urban areas between 2014 and 2017¹, a study published in the American Journal of Public Health revealed that a significant amount of MSM elsewhere live in PrEP-access deserts².

According to CDC data, between 2014 and 2017, PrEP use increased from just 6% to 35% while awareness of the prevention pill increased from 60% to 90% in urban areas. CDC researchers collected data from 20 urban areas, including Atlanta, Georgia; Baltimore, Maryland; Boston, Massachusetts; New York City, New York; Newark, New Jersey; San Francisco, California; and Seattle, Washington. In 2017, more than 80% of MSM in 17 of the urban areas were aware of PrEP.

In 2014 and 2017, a total of 18,610 sexually active MSM were interviewed, 9640 of whom were interviewed in 2014 and 8970 of whom were interviewed in 2017. The researchers narrowed down the cohort to 7873 MSM who had negative HIV test results but were at risk for infection.

“Although PrEP use in MSM in this analysis increased approximately 500% from 2014 to 2017, only approximately one in three men at risk for HIV infection reported using PrEP,” noted the researchers. “Models examining the impact of PrEP use on incidence predict that the use of PrEP by 30%-40% of MSM with PrEP indications in a community could result in approximately one-third of new HIV infections being averted over a 10-year period, with greater predicted impact if coverage is increased.”

In June, the United States Preventive Services Task Force for the first time issued a recommendation for PrEP for HIV prevention, offering the pill a grade A recommendation. As a result, coverage of the pill will increase in the coming years.

While almost all demographics reported increased use of PrEP between 2014 and 2017, some racial disparities remained even after accounting for income, health insurance, and region. For example, in 2017, 26% of blacks reported PrEP use, compared with 42% of whites. During the same year, 30% of Hispanic MSM reported using the pill. However, the difference in PrEP use between Hispanics and whites was no longer significant after controlling for income, health insurance, and region.

“The overall impact and efficiency of PrEP at averting new infections is greater in communities with a prevalence of HIV,” wrote the researchers. “Therefore, efforts focused on increasing PrEP use among black and Hispanic MSM, who have a higher prevalence of HIV infection, might substantially reduce the incidence of HIV infections.”

One of the most significant barriers blocking access to PrEP for MSM living in urban areas, even more so in less-urban areas, is geographic access to the pill, according to the study published in the American Journal of Public Health, which found that 1 in 8 MSM in 2017 lived a 30-minute 1-way drive away from the nearest PrEP provider, and a sizable minority (5%) lived a 60-minute drive away.

“This study of PrEP deserts illustrates that a substantial number of individuals for whom PrEP would be recommended have limited geographic access to care: more than 100,000 would need to travel more than 60 minutes round-trip per PrEP care visit, and more than 38,000 would travel more than 120 minutes.”

The researchers collected data on PrEP providers using PrEP Locator, a national, publicly available database, and identified 844,574 PrEP-eligible MSM from county-level urbanicity classification and population estimates.

PrEP providers were concentrated in urban areas, particularly around major cities. The data also revealed that large areas with the lowest levels of geographic access, reaching travel times of over 90 minutes, were common in low-population areas in the West and Midwest but were also found in more populated areas in the South. While PrEP deserts existed in every geographic area, less-urban areas accounted for the majority of PrEP-eligible populations living in 30-minute (55%) and 60-minute deserts (84%).

According to the researchers, the study findings point to the need for interventions to increase PrEP access, including provider training, alternative venue models, and telemedicine.

References:

1. Finlayson T, Cha S, Xia M, et al. Changes in HIV preexposure prophylaxis awareness and use among men who have sex with men—20 urban areas, 2014 and 2017 [posted online July 12, 2019]. MMWR Morb Mortal Wkly Rep. 2019;68:597—603. doi: 10.15585/mmwr.mm6827a

2. Siegler A, Bratcher A, Weiss K. Geographic access to preexposure prophylaxis clinics among men who have sex with men in the United States [published online July 18, 2019]. Am J Public Health. doi: 10.2105/AJPH.2019.30517