Racial and sex-based disparities as well as regional differences in pre-exposure prophylaxis (PrEP) uptake persist even in the U.S. Veterans Health Administration, a unified system that provides free or low-cost medications, according to new research presented at the IDWeek 2023 medical conference in Boston, Massachusetts. These findings point to the need for addressing stigma, structural racism, and other social determinants of health, study presenter Lewis S. Musoke, M.D., said.
In addition, “[w]e see barriers from the patient perspective, but there is a lot of education lacking for PrEP prescribing for providers,” noted Musoke, an assistant professor of medicine at Case Western Reserve University who is affiliated with the Veterans Affairs Northeast Ohio Healthcare System.
Participant Characteristics
The study was based on health records from the U.S. Veterans Healthcare Administration (VHA) from 2019-2022. People who have served in the U.S. military for a specific period and were honorably discharged are eligible for care at VHA facilities. Overall, more than 9 million people are enrolled in the VHA health care system.
During the study period, PrEP use in the system increased by 57% and new HIV diagnoses dropped by 12% overall but rose by 2.5% among women (sex assigned at birth). The COVID-19 pandemic likely led to a decrease in HIV testing rates and thus diagnosis rates.
Study Methods and Results
The number of veterans who filled at least one PrEP prescription during each calendar year in a given demographic group was divided by the number of veterans with a new HIV diagnosis in that group to arrive at the PrEP to need ratio (PnR). “Unfortunately, there is no ideal PrEP to need ratio,” explained Musoke. “[W]hat you really want is to have the percentage PrEP share match the percentage HIV share.”
For example, in 2022, Black veterans received 26% of PrEP prescriptions in the VHA system, while they accounted for 39% of new HIV diagnoses. In the U.S. West, 17% of all PrEP prescriptions went to Black people, and that racial group accounted for 16% of seroconversions. In the U.S. South, Black veterans received 34% of PrEP prescriptions but accounted for 54% of new HIV diagnoses.
Overall PnR rose from 6.2 in 2019 to 20.2 in 2022, with that ratio among white veterans remaining almost twice the PnR of Black veterans by the end of the study period. Geographically, the highest ratio was among facilities in the U.S. West, which also had no racial disparities. The lowest ratio was calculated in the U.S. South, and was especially low among Black people and women: PnR among Black veterans was less than half of PnR among white veterans, and PnR among women was slightly more than half of PnR among men.
Study limitations included a lack of data on care received outside the VHA system and limited data on sexual orientation and gender identity.
Next Steps
“Even though we have seen a lot of gains at the VHA in PrEP use over the last four years, we can all clearly see that there still remain racial and sex-based disparities along regional lines,” Musoke concluded. While access is clearly important, results show that the underlying reasons for racial disparities in PrEP use go beyond that–e.g., stigma, structural racism, and other social determinants of health.
To mitigate these disparities, “differentiated service delivery models are going to be key,” Musoke said. Implementation studies are needed to identify specific barriers and ways to overcome these. VHA also needs to develop targeted interventions, especially for Black people in the U.S. South.
Study Information
Abstract 2898, “PrEP Inequity Across Geographic, Racial and Sex Groups in a Nationwide US Veteran Cohort” was presented by Lewis S. Musoke, M.D., at IDWeek 2023 in Boston, Massachusetts.