Could disparities in PrEP uptake limit the public health benefit?
Authors: Phillip Keen, Benjamin R Bavinton
Journal: The Lancet Public Health (2020)

The population-level public health benefits of HIV pre-exposure prophylaxis (PrEP) in preventing HIV transmissions among gay, bisexual, and other men who have sex with men (hereafter referred to as MSM) have been shown by decreases in new HIV diagnoses in settings with high PrEP uptake, including where HIV testing and treatment are already high.1Grulich AE Guy R Amin J et al.Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study.Lancet HIV. 2018; 5: e629-e637Summary Full Text Full Text PDF PubMed Scopus (235) Google Scholar In New South Wales, Australia, following the establishment of a large PrEP implementation study, new HIV diagnoses among MSM in the 12 months after PrEP roll-out decreased by 25·1%, and recent HIV diagnoses (ie, diagnoses among men who acquired HIV in the previous 12 months) decreased by 31·5%.1Grulich AE Guy R Amin J et al.Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study.Lancet HIV. 2018; 5: e629-e637Summary Full Text Full Text PDF PubMed Scopus (235) Google Scholar In the UK, where PrEP uptake among MSM has increased rapidly since 2015,2O'Halloran C Sun S Nash S et al.HIV in the United Kingdom: towards zero HIV transmissions by 2030. 2019 report. Public Health England, London2019https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/858559/HIV_in_the_UK_2019_towards_zero_HIV_transmissions_by_2030.pdfDate accessed: August 5, 2020Google Scholar new HIV diagnoses among MSM decreased by 40% from 3165 in 2014, to 1908 in 2018.2O'Halloran C Sun S Nash S et al.HIV in the United Kingdom: towards zero HIV transmissions by 2030. 2019 report. Public Health England, London2019https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/858559/HIV_in_the_UK_2019_towards_zero_HIV_transmissions_by_2030.pdfDate accessed: August 5, 2020Google Scholar Furthermore, modelling suggests that the incidence of new HIV infections among MSM in the UK has decreased by 65% over this period.2O'Halloran C Sun S Nash S et al.HIV in the United Kingdom: towards zero HIV transmissions by 2030. 2019 report. Public Health England, London2019https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/858559/HIV_in_the_UK_2019_towards_zero_HIV_transmissions_by_2030.pdfDate accessed: August 5, 2020Google Scholar In their Article in The Lancet Public Health, Nadia Hanum and colleagues3Hanum N Cambiano V Sewell J et al.Use of HIV pre-exposure prophylaxis among men who have sex with men in England: data from the AURAH2 prospective study.Lancet Public Health. 2020; 5: e501-e511Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar make an important contribution to the literature on PrEP uptake among MSM. In their prospective cohort of MSM recruited from three genitourinary medicine clinics in south-east England, UK, PrEP awareness increased from 43% in 2013, to 92% in 2016. Similarly, PrEP initiation increased rapidly and, like in other settings, was highest among men who reported higher risk sexual behaviours.3Hanum N Cambiano V Sewell J et al.Use of HIV pre-exposure prophylaxis among men who have sex with men in England: data from the AURAH2 prospective study.Lancet Public Health. 2020; 5: e501-e511Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar Their findings also add to the increasing evidence of disparities in uptake of PrEP among MSM. PrEP uptake was more likely in men who reported high risk sexual practices and older men, and was less likely in men without a university education, who were not employed, had unstable housing, or had less or no money for basic needs.3Hanum N Cambiano V Sewell J et al.Use of HIV pre-exposure prophylaxis among men who have sex with men in England: data from the AURAH2 prospective study.Lancet Public Health. 2020; 5: e501-e511Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar A limitation of the study was that the analyses of factors associated with PrEP uptake were based on a sub-sample of 460 men, a high proportion of whom were of white ethnicity, highly educated, and in a stable economic situation.3Hanum N Cambiano V Sewell J et al.Use of HIV pre-exposure prophylaxis among men who have sex with men in England: data from the AURAH2 prospective study.Lancet Public Health. 2020; 5: e501-e511Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar Combined with the local nature of the study, these limitations mean that the study findings might not be generalisable to MSM in the rest of the UK. Nonetheless, the findings of Hanum and colleagues regarding disparities in PrEP uptake reinforce results from other settings. Research in the USA has shown that people from ethnic minorities and marginalised groups are less likely to initiate PrEP.4Mayer KH Agwu A Malebranche D Barriers to the wider use of pre-exposure prophylaxis in the United States: a narrative review.Adv Ther. 2020; 37: 1778-1811Crossref PubMed Scopus (140) Google Scholar Australian studies of MSM have shown that men who are younger, less educated or not in full-time work, and less engaged with gay communities were less likely to use PrEP.5Holt M Lee E Lea T et al.HIV preexposure prophylaxis cascades to assess implementation in Australia: results from repeated, national behavioural surveillance of gay and bisexual men, 2014–2018.J Acquir Immune Defic Syndr. 2020; 83: e16-e22Crossref PubMed Scopus (21) Google Scholar, 6Hammoud MA Vaccher S Jin F et al.HIV pre-exposure prophylaxis (PrEP) uptake among gay and bisexual men in Australia and factors associated with the nonuse of PrEP among eligible men: results from a prospective cohort study.J Acquir Immune Defic Syndr. 2019; 81: e73-e84Crossref PubMed Scopus (46) Google Scholar Similarly, in France, researchers found that MSM who were eligible for PrEP but not using it were more likely to be younger, students, less "out" about their sexuality, living in smaller cities, have less HIV prevention knowledge, and live in areas with fewer PrEP access points.7Annequin M Villes V Delabre RM et al.Are PrEP services in France reaching all those exposed to HIV who want to take PrEP? MSM respondents who are eligible but not using PrEP (EMIS 2017).AIDS Care. 2020; 32: 47-56Crossref PubMed Scopus (25) Google Scholar Maximising persistence of PrEP use among MSM who are at high risk is crucial to reducing HIV transmission. However, disparities similar to those for PrEP uptake have been associated with decreased PrEP adherence and discontinuation of PrEP. An Australian analysis of data on dispensing of government-subsidised PrEP showed that a low proportion of days covered by PrEP and PrEP discontinuation were associated with younger age, receiving a PrEP prescription from a low PrEP caseload physician, and prescription from a physician in an outer urban area.8Medland NA, Grulich AE, Keen P, et al. Successful national PrEP scale-up in Australia: evaluation of uptake, adherence, discontinuation and HIV seroconversion from April 2018 to September 2019 using national dispensing data. 23rd International AIDS Conference; San Francisco, CA, USA (virtual); July 6–10, 2020 (abstr OAC0802).Google Scholar Being a government benefit recipient was also associated with discontinuation.8Medland NA, Grulich AE, Keen P, et al. Successful national PrEP scale-up in Australia: evaluation of uptake, adherence, discontinuation and HIV seroconversion from April 2018 to September 2019 using national dispensing data. 23rd International AIDS Conference; San Francisco, CA, USA (virtual); July 6–10, 2020 (abstr OAC0802).Google Scholar In the USA, increased rates of discontinuation have been found in younger people and Black MSM.9Spinelli MA Buchbinder SP Pre-exposure prophylaxis persistence is a critical issue in PrEP implementation.Clin Infect Dis. 2020; 71: 583-585Crossref PubMed Scopus (26) Google Scholar The COVID-19 pandemic might present additional challenges to PrEP persistence. Among 864 MSM in an Australian online prospective cohort who were recruited in April, 2020, 42% of PrEP users stopped using PrEP after the introduction of COVID-19-related restrictions.10Hammoud MA, Grulich AE, Maher L, et al. Impact of physical distancing due to COVID-19 on sexual behaviours and HIV pre-exposure prophylaxis (PrEP) use among Australian gay and bisexual men: Implications for trends in HIV. 23rd International AIDS Conference; San Francisco, CA, USA (virtual); July 6–10, 2020 2020 (abstr OACLB0103).Google Scholar Although for many men this cessation of use was related to a concomitant reduction in sexual risk behaviour, concerns remain about appropriately timed re-initiation, especially among men who are younger, culturally diverse, economically disadvantaged, or less attached to the gay community. Although the rapid PrEP uptake among MSM most at risk of HIV in the UK and elsewhere is a good outcome, disparities in PrEP uptake and persistence are likely to lead to an uneven effect of PrEP in reducing HIV transmissions. Indeed, in the 12 months after rapid scale-up of PrEP in New South Wales, diagnoses with evidence of recent HIV infection decreased by 48·7% among Australian-born men, but by only 21·4% among Asian-born men, and increased by 23·5% among men born in other countries.1Grulich AE Guy R Amin J et al.Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study.Lancet HIV. 2018; 5: e629-e637Summary Full Text Full Text PDF PubMed Scopus (235) Google Scholar Decreases were also much greater in central Sydney (54·2%) than in outer suburban areas (7·3%).1Grulich AE Guy R Amin J et al.Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study.Lancet HIV. 2018; 5: e629-e637Summary Full Text Full Text PDF PubMed Scopus (235) Google Scholar Hanum and colleagues note that the forthcoming commissioning of PrEP by the National Health Service in England might increase PrEP use among eligible MSM and reduce socioeconomic disparities;3Hanum N Cambiano V Sewell J et al.Use of HIV pre-exposure prophylaxis among men who have sex with men in England: data from the AURAH2 prospective study.Lancet Public Health. 2020; 5: e501-e511Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar however, evidence from other settings suggests that mere public subsidy and availability might not be sufficient to ensure equitable uptake and public health impact. PrEP programme implementers and policy makers will need to understand these disparities and develop specific interventions to address them to harness the potential public health, community, and individual benefits of PrEP. We declare no competing interests. Use of HIV pre-exposure prophylaxis among men who have sex with men in England: data from the AURAH2 prospective studyPrEP awareness and use increased substantially from 2013 to 2018 among a cohort of MSM in England. Improving access to PrEP by routine commissioning by National Health Service England could increase PrEP use among all eligible MSM, but should include public health strategies to target socioeconomic and demographic disparities in knowledge and use of PrEP. Full-Text PDF Open Access