'Urgent Action' Needed to Prevent HIV in Black Americans

Heather Boerner

March 07, 2018

BOSTON — Nearly half of all Americans who qualify for pre-exposure prophylaxis (PrEP) because they are at elevated risk for HIV infection are black, but only 1% of those black Americans are actually using PrEP, new data show.

And this disparity is not because black Americans aren't being tested.

"Unequal access to and use of PrEP by black Americans is an urgent problem that must be addressed," said Dawn Smith, MD, from the Centers for Disease Control and Prevention (CDC).

Physicians "are really the key" to overcoming this disparity, she told Medscape Medical News. They should be talking to patients about prophylaxis and screening for HIV, even if they assume their patients don't need it.

Researchers and clinicians called the research "compelling" here at Conference on Retroviruses and Opportunistic Infections 2018.

The data Smith presented update estimates of HIV risk released by the CDC in 2015. Although there has been no real change in the number of Americans at risk for HIV since the previous data were released, the makeup of the at-risk group is significantly different.

New Estimates Show Stark Shortfalls

For instance, the 1.2 million people with indications for PrEP in 2015 were split nearly evenly between men who have sex with men and heterosexuals, whereas the new estimates show that nearly three of four people at risk are men who have sex with men. And data from local jurisdictions that account for geographic diversity in risk factors meant that estimates for heterosexuals and women were revised downward.

But it is the estimates of risk and PrEP eligibility that yield the most "striking" findings, Smith said. Of the 1.1 million US residents currently deemed to be good candidates for PrEP, 44% are black, 25% are Hispanic, and 26% are white.

This means that nearly half a million black Americans — including men who have sex with men and heterosexual women — could qualify for PrEP, she explained. Most of these candidates live in the South and the Midwest.

But when Smith looked at a survey of commercial pharmacies that includes about 85% of PrEP prescriptions in the United States to identify who is taking the HIV prevention pill — Truvada (Gilead Sciences) — she saw that need and usage numbers were flipped.

Only 1% of black Americans and 3% of Hispanics who are eligible for PrEP are taking it, whereas 14% of white Americans who are eligible are taking it.

"The fact that black and Hispanic Americans account for a significant majority of those with indications for PrEP and that coverage is lowest among black and Hispanic Americans is a call to urgent action," said Smith.

According to a poster presented at the meeting, if current disparities in PrEP prescribing continue, in 10 years, rates for white men who have sex with men who are at risk for HIV will drop by half, but for black men who have sex with men, rates will drop by only 23%. However, if black men who have sex with men begin taking PrEP at twice the rate of their white counterparts, HIV rates will drop by a significant 78%.

That's because black men who have sex with men tend to date other black men, Smith explained. With poorer viral suppression in black men who have sex with men who have HIV, the risk of acquiring HIV is just higher, even if these men are engaging in less risky behaviors.

"The high need for PrEP among black men who have sex with men and women is largely unmet. Until addressed, this situation will continue to result in increasing disparities in new HIV infections," she pointed out.

Striking and Troubling

These data are striking and troubling, said to Susan Buchbinder, MD, from the University of California, San Francisco, who presented data on the uptake of PrEP in San Francisco.

Her research on a plan to reduce new HIV infections to zero, using same-day treatment initiation and PrEP initiation for those at risk, showed that, although new HIV diagnoses in San Francisco dropped by 51% from 2012 to 2016, black Americans continue to use PrEP at lower rates than any other racial or ethnic group in the city.

And "there is a massive imbalance nationally," Buchbinder said. The data Smith presented "look much worse than the data in San Francisco," she pointed out, but the disparities remain.

"The reasons we have much higher rates of infection among black Americans are quite complex and they don't have to do with individual risk," she explained. "They have to do with sexual networks and access to care and antiretroviral treatment and viral suppression and institutionalized racism and a variety of other social and structural factors that are really driving this great disparity."

The good news, according to both Buchbinder and Smith, is that healthcare providers are uniquely positioned to correct this imbalance. Smith suggested that small shifts in clinical behavior could yield massive improvements in HIV prevention in black communities.

Just adding questions to intake forms about other sexually transmitted infections, reviewing charts to look for recent diagnoses, or having nurses ask a few questions about sexual health before the physician comes into the room could go a long way to opening the conversation about PrEP for people who might not, on the surface, seem to be at risk.

"I'm not saying spend an hour on this conversation, but find ways to quickly and simply determine the patients who may need PrEP," Smith said. "Then providers need to be willing to hear the answer. One problem we have is the providers who say, 'my patients aren't like that,' or 'this person is married so I don't need to ask them that question'."

Physicians need to help black Americans who might not engage in high-risk behavior, but who are at higher epidemiologic risk, bridge the gap between their risk perception and their ability to protect themselves, added Buchbinder.

"We need to have lower thresholds for black Americans to talk to them about PrEP," she explained. "We need to have conversations about PrEP and what the benefits are, and also understand what a person's concerns are about PrEP so they can be addressed."

This study was funded by the Centers for Disease Control and Prevention. Smith has disclosed no relevant financial relationships. Buchbinder reports receiving funds from Gilead Sciences.

Conference on Retroviruses and Opportunistic Infections (CROI) 2018: Abstracts OA86 and OA 87. Presented March 6, 2018.

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