Preexposure prophylaxis (PrEP) is the use of antiretroviral medicines by people who do not have HIV, to keep from getting it; taken consistently, it is proven to prevent infection. Gay, bisexual and other men who have sex with men (MSM) accounted for an estimated 68% of new HIV infections in the United States in 2016. In 2014 CDC issued clinical PrEP guidelines to health care providers and stepped up efforts to make people at risk aware of PrEP and to get more of them using it.
In February 2019, the U.S. Department of Health and Human Services proposed the Ending the HIV Epidemic initiative, aiming to cut new HIV infections by 90% during 2020–2030. Its first phase focused on Washington, DC; San Juan, Puerto Rico; 48 counties where most new diagnoses in 2016 and 2017 were concentrated; and seven states with a disproportionate share of HIV in rural areas. Expanding PrEP is one of its four pillars.
A CDC team used the National HIV Behavioral Surveillance (NHBS) system to measure how far PrEP awareness and use had moved among MSM between 2014 and 2017.
The survey
In 20 urban areas — covering 26 of the areas in the initiative’s first phase — NHBS staff recruited MSM at venues, interviewed them in person with a standard questionnaire, and offered anonymous HIV tests. Of 18,610 sexually active men interviewed across the two years, the analysis kept the 7,873 who tested HIV-negative and likely met the clinical indications for PrEP: in the past 12 months, one HIV-positive male partner or two or more male partners, plus condomless anal sex or a bacterial sexually transmitted infection (syphilis, gonorrhea or chlamydia).
The questions changed between years. In 2014 men were asked whether they had heard of HIV-negative people taking anti-HIV medicines to avoid infection, and whether they had done so before sex in the past year. In 2017 they were told what PrEP is and asked directly whether they had heard of it and taken it.
Awareness: 60% to 90%
Awareness rose from 60% in 2014 to 90% in 2017, and rose in every urban area. By 2017 more than 80% of men were aware of PrEP in 17 of the 20 areas and in every racial and ethnic group. The authors read this as a sign that awareness efforts are working — among them media and social-marketing campaigns such as Act Against AIDS — and note that national prevention goals were updated in 2015 to focus on the groups with the highest HIV prevalence, including Black and Hispanic MSM.
Use: 6% to 35%
PrEP use rose from 6% to 35%. The increase was statistically significant in every urban area and in almost every demographic group, with large gains among Black, Hispanic and young (18–29) men.
| Group, 2017 | Aware of PrEP | Used PrEP |
|---|---|---|
| All men in the analysis | 90.4% | 35.1% |
| Black | 86.2% | 26.2% |
| Hispanic or Latino | 86.6% | 30.0% |
| White | 94.5% | 42.4% |
| Aged 18–29 | 91.2% | 32.3% |
| Aged 30 and older | 89.7% | 37.6% |
| High school or less | 80.5% | 25.6% |
| College degree or more | 94.1% | 42.3% |
| No health insurance | 85.5% | 18.5% |
After allowing for income, health insurance and region, the gaps between Hispanic and white men and between younger and older men were no longer significant. The gap between Black and white men was: Black men remained significantly less likely to use PrEP. Use also rose with education and income.
Among the urban areas in 2017, use ranged from 5.7% in San Juan and 14.9% in Detroit up to 50.0% in Boston and 61.2% in San Francisco.
Why the gains are not enough
About one in three men at risk reported using PrEP. Models suggest that PrEP use by 30–40% of MSM who need it could avert about a third of new infections over ten years, with more averted at higher coverage — but cutting new infections by 90% in ten years will take far higher coverage.
PrEP does the most good where HIV is most common, so raising its use among Black and Hispanic MSM, who have a higher prevalence of HIV, could substantially reduce new infections. Because structural barriers linked to race affect access to good health care, CDC’s THRIVE demonstration projects in seven U.S. cities were building community collaboratives offering comprehensive HIV prevention and care to Black and Hispanic MSM.
Missed chances in the clinic
Only 39% of men who had seen a health care provider in the past year were using PrEP, despite their clear risk. CDC’s guideline recommends that providers take a routine sexual history from every patient, but some ask only when it bears on the complaint, and then only vaguely. Providers may need training to assess patients for PrEP and to feel confident discussing it. CDC’s Prescribe HIV Prevention toolkit offers answers to common questions, posters, patient materials, a sexual-history aid and continuing-education courses.
The authors’ message to clinicians: test patients for HIV routinely, assess HIV-negative patients for risk, and prescribe PrEP where it is needed.
Limitations
- NHBS measures risk over 12 months, not the guideline’s 6, and uses multiple partners as a stand-in for a nonmonogamous partner, so some men without a PrEP indication may be counted — which would make use look lower.
- The questions differed between years; the 2017 use question was more specific, so the rise may be understated.
- NHBS is not nationally representative.
- Data were not weighted for the sampling design, so some groups may be over- or underrepresented.
- Answers were self-reported; wanting to give the “right” answer may have inflated reported awareness and use.
Sources
Based on 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," Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; a work of the United States government in the public domain. The imported copy was cut off in one place; the missing results and both tables were taken from the same report’s full text in PubMed Central (PMC6741853).
Licence: CC0 1.0 (public domain) · Adapted from www.cdc.gov
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