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New research suggests a need “to push beyond PrEP equality and focus on PrEP equity” to increase PrEP uptake and provide PrEP to the people who need it most.

“We know that PrEP is effective at reducing the risk for HIV, but the impact of PrEP on reducing new cases of HIV depends on the extent to which the people using PrEP are those with the highest risk for HIV,” Patrick S. Sullivan, DVM, PhD, notes. “We wanted to understand not only how PrEP uptake varies among different groups of people but also how PrEP equity across groups has changed over time.”

For a study published in The Lancet Regional Health Americas, Dr. Sullivan and colleagues examined commercial pharmacy data to calculate PrEP users by race and ethnicity, sex, and US Census region between 2012 and 2021. They reported findings on PrEP use and the PrEP-to-need ratio (PnR), a metric of PrEP equity, based on race and ethnicity, sex, and region to evaluate trends.

Physician’s Weekly (PW) spoke with Dr. Sullivan to learn more about the study findings and the implications for PrEP use.

PW: What results from your study are important to underscore?

Dr. Sullivan: Our findings show that PrEP is not equitably reaching the people who need it most. Black and Hispanic people, as well as people in the Southern United States, are at higher risk for acquiring HIV than others, and so those groups need more protection with PrEP. However, we found that Black and Hispanic people and those in the Southern United States were underserved by PrEP relative to their risk for HIV.

Clinicians play a critical role in helping to increase the equitable use of PrEP; it is important to assess all patients for PrEP eligibility and to offer information on PrEP to those who might benefit from it. CDC PrEP guidelines currently recommend that PrEP be available to any patient who requests it, even if no specific risk behaviors are elicited.

According to our data, Black and Hispanic people were not served by PrEP equitably in 2022.

• In 2022, Black people represented 39% of all new HIV diagnoses (the highest among all races) but only accounted for 14% of PrEP users in 2023.
• In 2022, Black people represented 48% of new HIV diagnoses in the South but only accounted for 22% of PrEP users in the region in 2023.
• In 2023, states that had expanded Medicaid programs had an average PrEP use rate that was 1.3 times higher compared with states that did not have expanded Medicaid (175 vs 130 per 100,000)

Are the findings in the South related to the larger disparities observed?

There is a greater unmet need for PrEP in the Southern United States. Southern states are less likely to have Medicaid expansion and/or PrEP drug assistance programs, both of which have been associated with higher PrEP use. There is also, generally, more stigma observed in relation to HIV in the South, which can have a direct impact on willingness to use PrEP.

Disparities in HIV have persisted for decades. Are we seeing similar disparities in PrEP?

We certainly see similar disparities in PrEP use for some of these groups. For example, the risk for HIV is higher among Black people than for people of other races and ethnicities. In 2022, Black people represented 39% of all new HIV diagnoses—the highest among all races—but only accounted for 14% of PrEP users in 2023. An equitable outcome would be that Black people also represent around 40% of PrEP users, but they currently only represent 14%.

Did you observe other disparities beyond race and ethnicity?

Women are also underserved by PrEP relative to need. In 2022, women represented 18% of all new cases of HIV but only 8% of all PrEP users in 2023.

What are the implications of your findings?

To increase equitable PrEP use and curb rates of new HIV infections, we call on state and local health departments to monitor PrEP programs using PrEP equity data in addition to data on PrEP coverage. Based on the observed equity indicators, health departments might need to support interventions and implementation strategies that promise to get PrEP to the people who need it most.

Equitable PrEP programs will also have a substantially larger impact on achieving public health goals for ending the HIV epidemic than inequitable programs.

Clinicians should use HIV testing as an entry point to evaluate whether PrEP could be beneficial for patients who test negative for HIV and to provide linkage to services for care for those with HIV.

What would you like to see future research focus on?

We must reframe our programs and monitoring metrics to push beyond PrEP equality and focus on PrEP equity. Ultimately, PrEP equity is good public health: We will avert the greatest number of new HIV cases when we get PrEP to the people who need it most.