~1 Million Unreached: HIV Pre-Exposure Prophylaxis (PrEP) Is Not Reaching Everyone Most Vulnerable to HIV Acquisition
A holistic view of members is paramount to effective health and wellness. There are many factors that can influence positive outcomes with any treatment or prevention. |
Social determinants of health (SDOH) impact HIV PrEP use
To address the diverse and wide-ranging needs of people vulnerable to HIV acquisition, health systems must first acknowledge that SDOH (eg, housing, transportation, and socioeconomic status) may create barriers for HIV PrEP.2,3
While PrEP can be effective at preventing HIV acquisition when taken as directed, fewer than 25% of the approximately 1 million Americans who may benefit from PrEP are using it.4-6
Partly due to SDOH—MSM (men who have sex with men) and racial or ethnic minorities are communities highly impacted by new HIV diagnoses.7,8 |
Although many health plans do not have the ability to stratify members by determinants, like race or ethnicity, research has found that connecting members with services to address SDOH reduces health spending.10 |
Various studies have found evidence that links SDOH with vulnerability to HIV acquisition2 |
Contributors to PrEP disparities among transgender women and MSM
Nearly a decade ago PrEP was first approved. Around the same time, participants in the National Transgender Discrimination Survey reported a range of discrimination, from disrespect and harassment to violence and outright denial of service.11
Participants reported that they postponed medical care due to discrimination, and it can be inferred that lack of access to health services increased their risk of poor health outcomes.11
A frequently occurring challenge with research on transgender communities is the limited data capture that is unique to the population.12
Despite gaps in data collection, several studies have identified barriers that include, but are not limited to12:
- PrEP awareness,
- the cost of healthcare services, and
- stigma about HIV
For MSM, internalized feelings of shame along with social isolation may influence HIV testing decisions.12 Some may be reluctant to regularly test for HIV for fear of being outed, stigma from their providers, or because of internal struggles with their identity. Thus, regular HIV testing, a vital step in HIV prevention, is impeded by stigma.13
Sexual minority stigma, HIV-related stigma, and PrEP-related stigma were found to discourage positive attitudes about PrEP and HIV prevention strategies among gender, ethnic, and racial minority groups12
Social barriers to compliance among vulnerable populations
For communities of color living in the southern United States, PrEP uptake has been slow due to cultural barriers, stigma about HIV and MSM, geographical isolation, and the cost of healthcare services and medication.12
A review of several studies found that among study participants, adherence was consistently high when measured via self-report, pill count, and electronic methods (eg, medication event monitoring system [MEMS] and short message service [SMS] daily report), but generally lower when assessed via plasma drug concentrations of PrEP in the bloodstream.14
Although trial participants overreported their adherence to PrEP, it was unclear whether this was intentional or not.14
The researchers inferred that the participants’ reporting may have been influenced by social desirability bias, as participants in trials frequently receive adherence counselling and, therefore, understand the importance of compliance to PrEP.14
Common reasons for poor adherence included participants being unaware of their HIV vulnerability, side effects, perceived stigma, and dosing regimen incompatibility14
The prospect of social ostracism introduces structural barriers to accessing healthcare services and reducing PrEP uptake and adherence.14
Reasons for poor adherence to HIV PrEP14
In a study of young MSM of color in the United States, 39% had been ousted from their homes due to their sexual orientation, and 43% had spent at least one night on the street.15
Insecure housing, combined with the prevalence of transactional sex,* means that young MSM and young women (aged 13 to 29 years) frequently lack decision-making power over their bodies when it comes to sexual encounters.14,15
The aforementioned structural and social barriers, which reduce individuals’ autonomy, can generate considerable difficulty in maintaining sufficient adherence to the dosing regimen and in accessing health services.15
Moreover, the higher rates of stigma and bias associated with HIV and the LGBTQ+ communities, as well as higher rates of HIV criminalization laws, create additional barriers to PrEP uptake in southern regions in the United States.16
*Sex in exchange for money, housing, or some other benefit in an individual’s life.15
Systemic barriers can limit PrEP use for vulnerable populations
A study found that qualified health plans (QHPs) in the southern United States were more likely than QHPs in other US regions to require prior authorization for PrEP.16
Researchers were concerned because of the possibility that this practice could be considered a discriminatory benefit design,* as prior authorization was being used differently depending on the QHP's region.16
Arguably, the southern United States is most in need of access to PrEP given that it has the highest number of new HIV diagnoses each year.16
*Benefit design that prevents or delays people with complex or expensive conditions from obtaining appropriate treatment.16
Acknowledging SDOH and taking action to address gaps in treatment options may be an effective way to make PrEP use more equitable and to step closer toward the national goal of ending the HIV epidemic.17
Continued partnerships with community organizations and other payers/providers will go a long way to address SDOH.1
Consider barriers to PrEP when addressing your members' needs and satisfying your HIV prevention goals
References:
1. The ‘Edge Report Blog. Social determinants of health - what are payers doing? HealthEdge website. Accessed June 3, 2021. https://www.healthedge.com/blog-social-determinants-health-what-are-payers-doing
2. Center for HIV Identification, Prevention and Treatment Services and Center for Strengthening Youth Prevention Paradigms. HIV prevention at the structural level: the role of social determinants of health and HIV. Children’s Hospital Los Angeles website. Published 2012. Accessed June 3, 2021. https://www.chla.org/sites/default/files/atoms/files/SYPP_Social_Determinants_FINAL.pdf
3. Hoots BE, Finlayson T, Nerlander L, Paz-Bailey G; National HIV Behavioral Surveillance Study Group. Willingness to take, use of, and indications for pre-exposure prophylaxis among men who have sex with men–20 US cities, 2014. Clin Infect Dis. 2016;63(5):672-677.
4. Anderson PL, Glidden DV, Liu A, et al; iPrEx Study Team. Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Sci Transl Med. 2012;4(151):151ra125.
5. Centers for Disease Control and Prevention. Prevent new HIV transmissions by using proven interventions, including pre-exposure prophylaxis (PrEP) and syringe services programs (SSPs). Accessed June 7, 2021. https://www.cdc.gov/endhiv/prevent.html
6. Ending the HIV Epidemic. America's HIV epidemic Analysis Dashboard (AHEAD). Accessed June 3, 2021. https://ahead.hiv.gov/data/prep-coverage
7. U.S. statistics. HIV.gov website. Accessed June 3, 2021. https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics
8. Centers for Disease Control and Prevention. HIV Surveillance Report, 2018 (Updated); vol. 31. Published May 2020. Accessed June 3, 2021. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html
9. Half of black gay men and a quarter of Latino gay men projected to be diagnosed within their lifetime. News release. NCHHSTP Newsroom; February 23, 2016. Accessed June 3, 2021. https://www.cdc.gov/nchhstp/newsroom/2016/croi-press-release-risk.html
10. Geneia LLC. Social determinants of health & payers: getting started. Fierce Healthcare website. Published June 10, 2019. Accessed June 3, 2021. https://www.fiercehealthcare.com/sponsored/social-determinants-health-payers-getting-started
11. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey. National Center for Transgender Equality and National Gay and Lesbian Task Force. Published 2011. Accessed June 3, 2021. https://transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf
12. Matacotta JJ, Rosales-Perez FJ, Carrillo CM. HIV preexposure prophylaxis and treatment as prevention—beliefs and access barriers in men who have sex with men (MSM) and transgender women: a systematic review. J Patient Cent Res Rev. 2020;7(3):265-274.
13. Goldenberg T, Stephenson R, Bauermeister J. Community stigma, internalized homonegativity, enacted stigma, and HIV testing among young men who have sex with men. J Community Psychol. 2018;46:515-528.
14. Sidebottom D, Ekström AM, Strömdahl S. A systematic review of adherence to oral pre-exposure prophylaxis for HIV – how can we improve uptake and adherence? BMC Infect Dis. 2018;18(1):581.
15. Daughtridge GW, Conyngham SC, Ramirez N, Koenig HC. I am men’s health: generating adherence to HIV pre-exposure prophylaxis (PrEP) in young men of color who have sex with men. J Int Assoc Provid AIDS Care. 2015;14(2):103-107.
16. McManus KA, Powers S, Killelea A, Tello-Trillo S, Rogawski McQuade E. Regional disparities in qualified health plans’ prior authorization requirements for HIV pre-exposure prophylaxis in the United States. JAMA Netw Open. 2020;3(6):e207445. doi:10.1001/jamanetworkopen.2020.7445
17. Shaw ML. PrEP rates lowest among persons at highest risk of HIV with Medicaid coverage. AJMC website. Published March 3, 2021. Accessed June 7, 2021. https://www.ajmc.com/view/prep-rates-lowest-among-persons-at-highest-risk-of-hiv-with-medicaid-coverage
HVUWCNT210015 September 2021
