Editor’s Note: Lala Tanmoy (Tom) Das is a gay MD-PhD student at Weill Cornell Medicine in New York. Follow him @TanmoyDasLala. The opinions expressed in this commentary are those of the author. Read more opinion on CNN.
Newly released US Centers for Disease Control and Prevention data shows that as a nation, we are continuing to make significant strides toward ending the HIV epidemic in the US. However, there are stark racial and ethnic disparities.
Compared with 2017, new HIV infections in 2021 were down by 12%, driven largely by a 34% drop among young gay and bisexual men between the ages of 13 and 24. Contributing to this decline are several factors including greater HIV testing, higher rates of viral suppression of those who are HIV-positive and higher uptake of HIV pre-exposure prophylaxis (PrEP) medications, which are more than 99% effective in reducing HIV transmission by sex when taken as prescribed.
But as of 2019, Black people accounted for 40% of people with HIV, and Hispanic and Latino people accounted for nearly 30%, according to the CDC. And shockingly, in 2021, only 11% and 20% of Black and Hispanic people, respectively, who would potentially benefit from PrEP, were prescribed it. Whereas nearly 80% of White at-risk individuals received a prescription.
To address these gaps and make HIV prevention efforts more equitable, we need to prioritize several strategies.
To date, health care providers are the primary gatekeepers of PrEP prescriptions. And studies show that many providers continue to have incomplete knowledge of PrEP, hold misconceptions of its utility or feel uncomfortable prescribing it - amplified by racist biases about medication adherence in general and negative personal beliefs around sex.
Addressing these factors should be the first step toward further curtailing HIV rates. For example, educational sessions in conferences, easily accessible virtual resources and academic journal clubs may help dispel myths among health care providers about PrEP. Additionally, as proposed by The Joint Commission, the largest accrediting body of medical services and health care organizations in the US, ongoing investment in implicit bias trainings may help reduce bias in patient care and alleviate some of the dangerous side effects of discriminatory beliefs.
A larger and more robust endeavor to address health care workforce-mediated biases should also include conversations about PrEP in medical school, revisiting prescribing guidelines in postgraduate medical training, and a focus on higher recruitment of Black, Hispanic and LGBTQ+ health care professionals who can more effectively advocate for the needs of underserved populations. Importantly, more jurisdictions should also consider adopting California’s PrEP dispensing model in which individuals can pick up medications from pharmacists directly without needing a prescription.
Beyond provider factors, however, there are individual-focused initiatives that can promote equity in PrEP access and uptake. For example, culturally tailored resources for PrEP should be a priority among communities of color.
Several studies found that White men who have sex with men (MSM) have significantly higher PrEP awareness than Black and Hispanic MSM. An opportunity exists to bridge the gap through continued advertising on commonly used apps like Grindr and Scruff as well social media platforms such as Facebook and Instagram.
Community events during Pride Month in June can also be leveraged to discuss PrEP access (the once-daily pill as well as the newly FDA-approved long-acting injectable forms) and side effects, which have been a major deterrent from initiating PrEP for people of color. (Most medications can have some side effects; those of PrEP may include diarrhea, nausea, headache, fatigue and stomach pain. But for many they are well worth the protection from HIV transmission.) In parallel with these goals, patients should continue feeling empowered to initiate PrEP conversations with their providers to advocate for their own sexual health. And if access to LGBTQ+-friendly providers is limited, online PrEP services such as Mistr or health-center affiliated telePrEP programs may be viable alternatives.
PrEP can also be cost-prohibitive for many people without insurance who would benefit from it; brand-name Truvada costs nearly $1,800 per month, and the generic prescription costs $30 to $60 monthly. However, there are several government and insurance-mediated PrEP assistance programs such as Ready, Set, PrEP and ViivConnect that can offset the hefty price tags, irrespective of a person’s insurance status. Expanding states’ insurance laws, like New York has done, to specify that insurers must provide coverage for PrEP at no cost sharing can also mitigate cost concerns.
Ultimately, though, we need to keep fighting PrEP and HIV stigma to achieve the bold national goal of ending the HIV epidemic in the US by 2030. Although it’s encountered by nearly all MSM communities, Black and Hispanic individuals frequently report being shamed as promiscuous for using PrEP, as well as experiencing conflicts in romantic relationships and judgment from health care providers for using these HIV prevention drugs. Racism and homophobia, especially in conservative parts of the country, further stymie PrEP access and compound stigma.
To combat these negative experiences, we need to prioritize public health campaigns that normalize PrEP for users and providers alike, showcase real-life testimonials from Black and Hispanic individuals on PrEP, and engage celebrities to promote PrEP on social media channels.
Collaborative efforts involving all stakeholders, including at-risk individuals, peers, health care providers and insurance enterprises, as well as local and national governments, are critical to the path forward in eliminating racial and ethnic disparities in the overall HIV landscape.
