US, SF increase PrEP uptake, but disparities remain

  • by John Ferrannini, Assistant Editor
  • Tuesday November 21, 2023
Share this Post:
Carl Schmid is executive director of the HIV + Hepatitis Policy Institute. Photo: Washington Blade/Michael Key
Carl Schmid is executive director of the HIV + Hepatitis Policy Institute. Photo: Washington Blade/Michael Key

A little over one-third of people nationwide who could benefit from PrEP were on it in 2022, but there continue to be major disparities among white, Black, and Latino Americans, according to data from the federal Centers for Disease Control and Prevention.

Numbers from San Francisco show a much larger proportion of people on PrEP than nationally, and show the same racial and ethnic disparities, but less dramatically so.

PrEP, or pre-exposure prophylaxis, refers to the use of antiviral drugs to prevent people exposed to HIV from becoming infected. The pill Truvada was first approved for PrEP use in 2012 by the U.S. Food and Drug Administration; since then the FDA has also approved the pill Descovy for some groups, and the drug Apretude as an injectable treatment.

"It is a huge disparity," Carl Schmid, a gay man who is the executive director of the Washington, D.C.-based HIV + Hepatitis Policy Institute, told the Bay Area Reporter. "I think we need outreach to the community — the Black community, the Latino community, women. I think right now there probably isn't enough."

The data in the CDC's "Core Indicators for Monitoring the Ending the HIV Epidemic Initiative", show that of the 1.2 million people believed to be eligible for PrEP, the number using it rose from 20% in 2021 to 36% in 2022.

The largest uptake occurred among white Americans. In 2021, 78% of those eligible were on PrEP, and in 2022 that rose to 94%. However among eligible Black Americans — only 11% of whom were on PrEP in 2021 — it's only 13%. Uptake among eligible Latino Americans rose 21% to 24%, and among eligible women from 12% to 15%.

These disparities aren't new, as the B.A.R. has previously reported over the years. In 2021, the CDC reported that HIV infections had declined, but that racial disparities remained among PrEP users. Also that year, the CDC released a report showing that Black and Latino gay and bisexual men were not seeing the same improvements in reducing HIV rates and PrEP use as their white counterparts.

The CDC's latest report offers more of the same evidence.

Brian Ragas is the director of Black health at the San Francisco AIDS Foundation. Photo: From LinkedIn  

Brian Ragas, director of Black health at the San Francisco AIDS Foundation, told the B.A.R. that the problems regarding PrEP usage are the same things that lead to other racial health care disparities, including discrimination.

"We have known for a long time that there are many barriers to PrEP care — and other forms of medical and HIV care — for Black Indigenous and people of color (BIPOC) in the U.S.," Ragas stated. "Racism, stigma, discrimination, and lack of cultural competencies in the medical and health care fields can make PrEP services and care inaccessible to many who may benefit from it. In order to close disparities in HIV prevention and care, it is a priority to reach BIPOC, queer, trans, and Latine communities with culturally relevant and tailored programs and services."

Of the ongoing disparities in usage of PrEP, Schmid said that "it really shows the work we have to do."

"It's good to have so many white people protected from HIV, but we want anyone who needs PrEP to be on it regardless of ethnic or racial background," Schmid said.

Schmid pointed out two things he thinks can be done — first is protecting federal funding for community health centers.

The U.S. Department of Health and Human Services' PrEP program for community health centers currently supports 80,000 people on PrEP at 411 sites. However, as the B.A.R. previously reported, House Republicans want to cut funding for the Ending the HIV Epidemic Initiative, which had been launched under the administration of Republican then-president Donald Trump.

The second step to take, Schmid said, is to ensure providers are better informed.

"You need a prescription for PrEP," Schmid said, referring to most parts of the country but not California. "So we need outreach to providers to make sure they are competent in dealing with and addressing concerns. No stigma, no matter who."

In California, a prescription isn't needed for a one-month supply of PrEP. Gay state Senator Scott Wiener (D-San Francisco), and gay then-Assemblymember Todd Gloria (D-San Diego) co-authored Senate Bill 159 in 2019 that allows pharmacists to furnish a 30-day supply — and up to a 60-day supply — without a prescription. Governor Gavin Newsom signed the bill, which went into effect nearly four years ago. (Gloria is now the mayor of San Diego.)

However, this year, Newsom vetoed a bill that would have closed loopholes and strengthened protections in existing law to ensure that California health insurers continue to provide free and complete coverage for preventive services like PrEP. As the B.A.R. reported, Newsom did so over concerns the legislation, AB 1645 authored by gay Assemblymember Rick Chavez Zbur (D-Santa Monica/West Hollywood), would result in higher premium costs for consumers.

Also in the recent legislative session, Wiener had sought to expand that access under SB 339. But he pulled the bill in September after the Assembly Appropriations Committee inserted language into it he considered to be a "poison pill amendment" counter to his legislative aim of expanding access to the HIV prevention medication known as PrEP. As the B.A.R. reported, the bill sought to increase the amount of PrEP that pharmacists are authorized to provide without a doctor's prescription.

Wiener told the B.A.R. on November 20 that "to end HIV infections, everyone at risk needs access to PrEP. We aren't even close in reaching that goal, and we need to make sure all communities have full access."

Wiener, who has publicly acknowledged he takes PrEP, stated to the B.A.R. that the bill "will move forward early next year."

Other local community health advocates acknowledged the disparities presented in the CDC data while offering ideas to lessen them

Tatyana Moaton, Ph.D., is the director of strategic innovations and partnerships at the San Francisco Community Health Center. Photo: Courtesy SF Community Health Center  

Tatyana Moaton, Ph.D., the director of strategic innovations and partnerships at the San Francisco Community Health Center, told the B.A.R. that "these statistics reveal a critical gap in our health care system's ability to effectively reach and serve diverse populations."

"A multifaceted approach is needed to address this issue," she stated. "This includes increasing awareness and education about PrEP in minority communities, improving access to health care services, and working closely with community leaders and organizations to build trust and understanding. Additionally, tailoring health care services to meet the unique needs of different communities is crucial."

Moaton called on state and federal governments to fund initiatives to combat HIV and AIDS.

"San Francisco Community Health is committed to working toward bridging these gaps and ensuring equitable health care for all, particularly in HIV prevention and treatment," she stated. "We constantly strive to innovate and partner with other organizations to amplify our impact in making health care inclusive and accessible to all."

The CDC currently recommends PrEP be considered for those who are HIV-negative and have had vaginal or rectal intercourse in the past six months and have a sexual partner with HIV (especially if their viral load is unknown or detectable), or have not consistently used condoms, or have been diagnosed with another sexually transmitted disease in the past six months.

It is also recommended for people without HIV who inject drugs and have an injection partner with HIV or share needles, syringes or other equipment to inject drugs with any other person.

PrEP is recommended for anyone who has been prescribed nonoccupational post-exposure prophylaxis — antiretrovirals taken for a month after sex to prevent HIV infection, also known as PEP — and has continued risky behavior, or who has needed PEP multiple times.

PrEP can reduce the risk of sexual HIV transmission by 99%, the CDC states, and can reduce the risk of transmission from injection drug use by 74%.

SF has higher PrEP uptake, less racial disparity
Schmid pointed out that the data were "not consistent around all different states."

For example, California tracked with the national numbers, with an increase in PrEP coverage from 30.5% to 37.4% from 2021-2022. The state-by-state data did not include a racial or ethnic breakdown.

Data was also provided for eight California counties, including San Francisco, Alameda, and Los Angeles. San Francisco had 83.9% of the eligible population covered by PrEP, an increase from 75.9% in 2021. It was the only county in California in 2022 to have over 50% of those eligible covered by PrEP: Alameda and Los Angeles counties were at 30.4% and 34.8%, respectively.

Schmid called San Francisco's percentage "remarkably high" and the result of "good health programs there and leadership promoting PrEP with the health department. We need that elsewhere."

The other counties in the U.S. to also have over 50% of those eligible on PrEP in 2022 are Queens, Kings, and New York counties in New York state (home of the New York City boroughs of Queens, Brooklyn, and Manhattan, respectively); Miami-Dade County in Florida; Suffolk County (home of Boston) in Massachusetts; Travis County (home of Austin) in Texas; Philadelphia County in Pennsylvania; and King County (home of Seattle) in Washington state. The District of Columbia also had over 50% of those eligible on PrEP.

Schmid speculated that "the gay population there [in San Francisco] is more white too, as well. That could be a reason."

To find out, the B.A.R. asked the Department of Public Health for a racial and ethnic breakdown of people who are on PrEP.

A spokesperson, who did not provide their name, responded that "there is not a citywide PrEP registry that reports how many eligible San Franciscans are on PrEP," but did provide data specific to those who are on PrEP among patients at San Francisco City Clinic in the South of Market neighborhood.

The most recent statistics, from 2021, show 71% of Asian or Pacific Islander men who have sex with men who are patients at the clinic are on PrEP, followed by 70% of Latino men, 69% of white men and 57% of Black men.

The percent for Black San Franciscans went down from 2020, when 62% were on PrEP, though the numbers for all groups are substantially higher than in 2017, when none had a majority on PrEP.

However, the disparity was much less then, too — a spread of only 8%. Forty-eight percent of Asian and Pacific Islander men who have sex with men were on PrEP, compared to 40% of Black men who have sex with men on PrEP.

The city's data also showed an age disparity — only 57% of men over 55 who have sex with men were on PrEP compared to 75% of those ages 35-44, the highest uptake group. Even 70% of men aged 18-24 were on PrEP in 2021.

"We believe it is important to have a network of sites with low-barrier access to care across San Francisco to ensure people feel empowered and supported to seek sexual health care," the DPH spokesperson continued, who echoed Schmid's statements about unfinished work.

"The figure shows an increase over time with relatively high uptake across race and ethnicity, but we recognize there is still work to do," the spokesperson stated. "HIV diagnosis rates in San Francisco are higher among Black/African American and Latinos compared with whites; eliminating these disparities and achieving our HIV Getting to Zero goals for all populations through a collaborative, community-centered approach is a priority.

"We know there are many factors and structural barriers that prevent access to sexual health care and services, and we always will act as a safety net and strive to support those without access to insurance or face barriers to accessing care," the spokesperson added.

San Francisco's Getting to Zero campaign, which has been underway for several years, aims to reduce HIV transmission and HIV-related deaths by 90% by 2025. In 2021, there were 160 HIV cases in San Francisco, as the B.A.R. reported. That year also marked the first time that gay and bisexual men who don't inject drugs accounted for less than half of new HIV cases in San Francisco.

The health department has created media campaigns to reach out to the Black and Latino communities, the spokesperson continued.

"Outside of traditional hospital and clinic settings in the SFDPH Health Network, SFDPH developed a framework called Health Access Points (HAPs) with community partners to address populations experiencing disparities in the rate of HIV infections and care outcomes," the spokesperson continued.

"There are HAPs for seven priority populations, including Black/African Americans and Latinx persons. The goal of the HAPs is to provide equity-focused, stigma-free, and low barrier access to person-centered, comprehensive HIV, HCV, and STI treatment services that include access to PrEP and PrEP navigation or referrals, among other services. We are also working to equitably implement new prevention tools such as injectable PrEP, as an approach to address and eliminate disparities."

Help keep the Bay Area Reporter going in these tough times. To support local, independent, LGBTQ journalism, consider becoming a BAR member.