By Rebecca Bowers

EXECUTIVE SUMMARY

An analysis of national data indicates that only a small percentage of Americans who could benefit from pre-exposure prophylaxis (PrEP) have received a prescription for it.

  • Although two-thirds of people who potentially could benefit from PrEP are African-American or Latino, they account for the smallest percentage of prescriptions, the data suggest.
  • Data indicate that although about 500,000 African-Americans and nearly 300,000 Latinos potentially could have benefited from PrEP, prescriptions were filled at retail pharmacies or mail order services for only 7,000 African-Americans and 7,600 for Latinos during a similar time period.

An analysis of national data indicates that only a small percentage of Americans who could benefit from pre-exposure prophylaxis (PrEP) have received a prescription for it.1 Although two-thirds of people who potentially could benefit from PrEP are African-American or Latino, they account for the smallest percentage of prescriptions, the data suggest.

To conduct the analysis, researchers at the Centers for Disease Control and Prevention (CDC) looked at available data on PrEP prescriptions from a national database of prescriptions filled by commercial U.S. pharmacies. The analysis indicates that although about 500,000 African-Americans and nearly 300,000 Latinos potentially could have benefited from PrEP, prescriptions were filled at retail pharmacies or mail order services for only 7,000 African-Americans and 7,600 for Latinos during a similar time period (September 2015-August 2016).1

When looking at the same time period for white U.S. residents, the analysis indicates that of the 300,000 whites who potentially could have benefited from PrEP, just 42,000 prescriptions were filled at retail pharmacies or mail order services.1 The data were presented at the 2018 Conference on Retroviruses and Opportunistic Infections in Boston.

“One of our most powerful tools for HIV prevention remains largely on pharmacy shelves,” says Jonathan Mermin, MD, MPH, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. “PrEP can be a potent prescription that strengthens prevention options for people who are at high risk for HIV infection.”

Help Patients at Risk

In 2012, the Food and Drug Administration approved the use of 300 mg tenofovir disoproxil fumarate and 200 mg emtricitabine as PrEP in combination with safer sex practices. In 2014, the CDC issued clinical guidance for using these anti-HIV drugs in uninfected patients who are at substantial risk of infection.2 Research indicates that PrEP can reduce HIV infection rates; when taken daily as directed, PrEP can reduce the risk of HIV infection by more than 90%.3

To help focus provider and public education efforts, CDC researchers have developed a new method for estimating where PrEP need is greatest. Their approach combines data on risk behavior with the latest information on HIV diagnoses nationally and in states.

About 1.1 million Americans are at substantial risk for HIV and should be offered PrEP, the analysis indicates.1 The figures show that only 90,000 PrEP prescriptions were filled in commercial pharmacies in the year examined.1 Analysts say that actual PrEP use may be somewhat higher than estimates because some patients receive their PrEP medication through avenues such as demonstration projects, non-commercial pharmacies, or managed care plans that operate private prescription drug programs. The CDC says commercial pharmacies account for about 85-90% of all PrEP prescriptions.

Delve Into the Numbers

A second presentation at the 2018 conference from a research team led by Patrick Sullivan, PhD, professor of epidemiology at Emory University’s Rollins School of Public Health, compared the distribution of PrEP users to the need for PrEP based on where new HIV cases are occurring.4 Using data from the U.S. census and CDC HIV case surveillance, the scientists developed a “PrEP-to-need” ratio, dividing the number of PrEP prescriptions by the number of new HIV diagnoses. A higher ratio indicates areas with better coverage of PrEP for those who need it, the researchers explain.

The analysis indicates that 61,300 people nationwide had active PrEP prescriptions in the second quarter of 2017, or 23.0 per 100,000 people. With 15.0 new diagnoses of HIV per 100,000 people nationwide, the analysis yields a PrEP-to-need ratio of 1.5.

Regarding geographic regions, the analysis shows that the Northeast (with the highest PrEP use rate at 38.5, and 13.3 new diagnoses of HIV per 100,000) displayed the highest PrEP-to-need ratio at 2.9. The South registered a low rate of PrEP use at 18.8 and a high rate of diagnosis at 20.9 per 100,000, yielding the lowest PrEP-to-need ratio at 0.9. The Midwest and West yielded PrEP-to-need ratios of 2.1 and 1.8, respectively.4

Researchers also calculated the PrEP use and PrEP-to-need ratios for different demographic groups. The PrEP usage rate among women was 2.0 and the new diagnosis rate was 5.5 per 100,000, equaling a PrEP-to-need ratio of 0.4. On the other hand, the PrEP usage rate among men was 45.0 and the diagnosis rate was 24.9 per 100,000, resulting in a PrEP-to-need ratio of 1.8. People 24 years of age and younger, or 55 years of age and older, exhibited lower PrEP-to-need ratios than people between these age groups.4 Lower rates of PrEP use and lower PrEP-to-need ratios were found in states that have a higher proportion of people who are living in poverty and who don’t have health insurance, as well as in states that did not implement Medicaid expansion under the Affordable Care Act, data suggest.

AIDSVu, a project presented by Emory University’s Rollins School of Public Health in partnership with Gilead Sciences, Inc., and the Center for AIDS Research at Emory University, provides a visualization of the HIV epidemic across the United States. Its interactive maps illustrate geographic variations in the HIV epidemic, and reveal how the disease affects different communities. In March 2018, AIDSVu issued its first-ever interactive state-level maps showing a 73% increase year over year in persons using PrEP across the United States from 2012 to 2016, with 77,120 PrEP users in 2016.

Men and patients 25-44 years of age were more likely to be PrEP users, the mapping program shows. More than 90% of all PrEP users in 2016 were male, and men accounted for 81% of all new HIV diagnoses in 2016. In the same year, 64% of all PrEP users were 25-44 years of age. This age group represented 54% of all new HIV diagnoses during the same period. The South accounted for just 30% (23,091 persons) of all PrEP users in 2016. However, the region represented 52% of all new HIV diagnoses in that year. Regarding the rate of PrEP use, the five states with the highest rates in 2016 were New York, Massachusetts, Rhode Island, Washington, and Illinois.

“We hope that the newly available data on AIDSVu will allow health departments, elected officials, medical professionals, and community leaders to better understand and visualize the realities of who has access to this important prevention tool so they can develop programs and policies to decrease barriers,” says Sullivan, who serves as principal scientist for AIDSVu.

REFERENCES

  1. Smith DK, Van Handel M, Grey JA. By race/ethnicity, blacks have highest number needing PrEP in the United States, 2015. Presented at the 2018 Conference on Retroviruses and Opportunistic Infections. Boston; March 2018.
  2. Centers for Disease Control and Prevention. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States — 2014: A Clinical Practice Guideline. Available at: http://1.usa.gov/1n3IJzr. Accessed April 20, 2018.
  3. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med 2012;367:399-410.
  4. Siegler AJ, Mouhanna F, Giler RM, et al. Distribution of active PrEP prescriptions and the PrEP-to-need ratio, US, Q2 2017. Presented at the 2018 Conference on Retroviruses and Opportunistic Infections. Boston; March 2018.