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Figures show PrEP usage lags

by Liz Highleyman

CDC researcher Dawn Smith. Photo: Liz Highleyman
CDC researcher Dawn Smith. Photo: Liz Highleyman  

While PrEP usage has reached more than 75,000 people in the U.S., attendees at an annual conference were told the HIV prevention medication is still not reaching those who could benefit from it, including minority men who have sex with men.

Figures released by AIDSVu in conjunction with the 25th Conference on Retroviruses and Opportunistic Infections in Boston show that the number of people taking PrEP in the U.S. reached more than 77,000 in 2016.

However, PrEP is only reaching a small proportion of those who could benefit from it, according to a new analysis by the Centers for Disease Control and Prevention. Among the more than 1 million people who were potential candidates for PrEP in 2015, only 8 percent received it. And while African-Americans and Latinos make up about two-thirds of people who could benefit, they are much less likely than whites to be using PrEP.

"This is a call to urgent action. We must end this inequity if we are to end the HIV epidemic for all Americans," Dawn Smith of the CDC's Division of HIV/AIDS Prevention said at the conference. "After six years, we're nowhere near tapping the full potential of PrEP as a hugely powerful HIV prevention tool."

AIDSVu numbers
The Food and Drug Administration approved Truvada (tenofovir/emtricitabine) for HIV prevention in July 2012. Adoption was initially slow, but by late 2013 it began to rise steeply as gay men started promoting PrEP within their communities. However, it has been difficult to estimate the total number of people using PrEP because this information is not centrally collected.

For the past several years Foster City-based Gilead Sciences, the maker of Truvada, has reported PrEP estimates based on surveys of commercial pharmacies. At the International AIDS Society Conference on HIV Science last summer, Gilead researchers reported that an estimated 120,000 people had ever started PrEP since 2012.

Now, Gilead has teamed up with researchers at Emory University's Rollins School of Public Health to make the latest PrEP numbers available via AIDSVu, an interactive online map of the U.S. HIV/AIDS epidemic.

The new figures are based on data from more than 54,000 pharmacies, 1,500 hospitals, 800 outpatient facilities, and 80,000 physician practices across the country. It includes prescriptions paid for in cash or by private insurance, Medicaid or Medicare, or patient assistance programs. It does not include PrEP obtained through demonstration projects, military health systems, or managed care providers like Kaiser Permanente that operate their own pharmacies.

The data show that 77,120 people were using PrEP in 2016, up from 8,768 in 2012. This represents a 73 percent annual increase since 2012, or an overall increase of 877 percent over the entire four-year period. But the aggregate data hide some notable demographic and geographic disparities.

"PrEP is a revolution in HIV prevention and has the potential to dramatically reduce new HIV infections; however, significant disparities in the use of PrEP exist across the country," said AIDSVu principal scientist Patrick Sullivan. "Expanding access to PrEP is a core component of Getting to Zero campaigns in cities and states across the country and is one of four key focus areas in the National HIV/AIDS Strategy."

Men accounted for 93 percent of PrEP users in 2016. Although women account for about 19 percent of all new HIV diagnoses nationwide, they made up only 7 percent of PrEP users. About two-thirds of PrEP users are in the 25-to-44 age range, a group that accounts for just over half of new diagnoses.

People in the Northeast were around twice as likely to use PrEP as those in the West, South, or Midwest. Although more than half of new HIV diagnoses in 2016 occurred in the South, this region was home to just 30 percent of PrEP users.

After adjusting for population size, New York, Massachusetts, Rhode Island, Washington, and Illinois had the highest rates of PrEP use. AIDSVu does not break down that data by city, so it doesn't show the contribution of cities like San Francisco with large numbers of PrEP users.

"The AIDSVu maps provide us with a clear visual that confirms with data many things we already knew and suspected," HIV prevention advocate Damon Jacobs told the Bay Area Reporter. "We are starting to see new infections decline in some communities that have strong PrEP uptake, and I hope that in the near future we will focus our attention and resources in areas where there are clear disparities."

Blacks have higher PrEP need
It is widely acknowledged that African-Americans have the highest HIV incidence and lowest PrEP usage rates, but this is harder to quantify because prescription data often don't include information on race or ethnicity.

At CROI, Smith presented results from a new CDC analysis of PrEP use and need by race/ethnicity.

The new state-level estimates suggest that 1.45 million Americans were at substantial risk for HIV and eligible for PrEP in 2015. But only about 90,000 PrEP prescriptions were filled between September 2015 and August 2016, meeting just 8 percent of the need.

Approximately 500,000 African-Americans and nearly 300,000 Latinos nationwide could potentially benefit from PrEP, but only 7,000 prescriptions were known to have been filled for blacks and 7,600 for Latinos during this period. That is, just 1 percent of eligible blacks and about 3 percent of Latinos were using PrEP. There was a smaller but still considerable gap between the 300,000 white people who could potentially benefit from PrEP and the 42,000 - or 14 percent - who received prescriptions.

Looking at gay and bisexual men, who account for a large majority of new HIV diagnoses, about 814,000 were eligible for PrEP, of whom 38 percent were black, 29 percent were white, and 27 percent were Latino. In addition, about 258,000 heterosexuals - two-thirds of them women - and 73,000 people who inject drugs were eligible for PrEP.

"One of our most powerful tools for HIV prevention remains largely on pharmacy shelves," Dr. Jonathan Mermin, director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, said in a CDC news release. "PrEP can be a potent prescription that strengthens prevention options for people who are at high risk for HIV infection."

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