PrEP Prescriptions Rise Sharply, but Unequally, in New York City

Attendees observe a session at IDWeek 2017
Infectious Diseases Society of America

In New York City, the number of people taking PrEP (pre-exposure prophylaxis), the once-daily HIV prevention pill, has skyrocketed in recent years -- yet prescriptions are more likely to be written for affluent white men than others, according to a study presented on Oct. 5 at IDWeek 2017 in San Diego, California.

After the U.S. Food and Drug Administration first approved tenofovir/emtricitabine (Truvada) for PrEP in 2012, uptake was surprisingly slow for a drug that represented a groundbreaking step forward in HIV prevention. In more recent years, however, this has begun to change significantly.

"Between 2014 and 2016, we saw a nine-fold increase in prescribing PrEP among a sample of 600 clinics" in New York City, said Paul Salcuni, M.P.H., lead author of the study and lead data analyst for prevention, Bureau of HIV/AIDS Prevention and Control at the New York City Department of Health and Mental Hygiene.

Put another way, the number of PrEP prescriptions increased by 976% in New York City over a two-year period, according to Salcuni. By comparison, the number of PrEP prescriptions in the U.S. rose overall by 523% from 2013 to 2015, according to data presented in 2016 by Gilead, the pharmaceutical company that sells tenofovir/emtricitabine for PrEP.

This PrEP uptake was far from consistent across New York City's demographic groups, however.

The researchers collected data from 602 practices in New York, breaking down patient data by age group (either 18-29 or 30-100), sex (male or female), race and ethnicity (Asian, black, Hispanic, white, other or missing). They broke down clinical practices prescribing PrEP by geographic location (either in Manhattan or in a surrounding borough), by the type of practice (community health center, hospital or independent), by the number of infectious disease specialists and by the portion of patients from high poverty neighborhoods.

The researchers then looked at the overall trends, finding that the vast majority of prescriptions (95%) were among men. According to the adjusted rate ratio, black, Hispanic and Asian men were about half as likely to receive a prescription compared with white men. In addition, men under the age of 30 were 2.8 times more likely to be prescribed PrEP compared with older men.

Clinics with at least one infectious disease doctor had a prescription rate 8.4 times higher than those without one. Compared with independent practices, community health clinics and hospitals were more likely to prescribe PrEP (4.9 and 0.4 times as likely, respectively).

Additionally, according to the unadjusted rate ratio, the portion of patients living in higher income areas was associated with prescription rates. The researchers noted in their abstract that at first patients from high poverty neighborhoods were less likely to be prescribed PrEP, but this association diminished over the two years of the study.

Male patients in Manhattan were 8.5 times more likely to be prescribed PrEP compared with those outside Manhattan. "However, these results should be interpreted with caution, given that this sample does not include some key clinical practices in New York City known to reach the underserved and/or prescribe PrEP, nor does the sample include NYC Health Department's eight Sexual Health Clinics," Salcuni said at a press conference. He also explained that the study sample included only clinics using an electronic health record (EHR) vendor called eClinicalWorks; therefore, it excluded some large hospitals and the community health network Callen-Lorde, which do not use the same EHR vendor.

Broadly, Salcuni said, "the trends shown here justify the need for programs that ensure equitable access to PrEP for men of color, for women and for people with inadequate access to services in/near the city center."

"New HIV infections are disproportionately occurring in black and Hispanic people," concurred Rajesh Gandhi, M.D., director of HIV clinical services and education at Massachusetts General Hospital and one of the HIV Medicine Association representatives on the IDWeek program committee. "We need to do a better job of expanding the use of this effective HIV prevention tool, including among men and women of color."

A Closer Look at New York City's PrEP Education Campaigns

In late 2015, the New York City Department of Health launched a full-scale advertising campaign around PrEP and HIV prevention in its subways and on mass-transit buses, with colorful posters depicting happy couples and the tagline "Play Sure."

But the city's campaign wasn't just about educating the public. Even earlier, in January 2014, the health department had launched a PrEP and post-exposure prophylaxis (PEP) campaign for care providers, focusing on one-on-one provider education, Salcuni said. According to Salcuni, the campaign has visited over 2,500 providers at more than 1,300 clinical sites in New York City to date.

"We prioritize practices located in high-poverty neighborhoods, independent practices and primary care providers, who have been shown in other studies to be less comfortable prescribing PrEP compared to infectious disease specialists, despite their unique position to identify potential patients," said Salcuni.

To better meet the needs of women who are good candidates for PrEP, the health department is planning to launch a new PrEP and PEP campaign focused on women's health providers, Salcuni said.

Overall, it's clear that "PrEP works and needs to be utilized more," Gandhi said. "One aspect is having a broader variety of clinicians be familiar with it and also making sure the public is generally aware of the benefits, so they can also ask their physicians.

"I think NYC is doing great work in that regard, and we hope other cities will soon follow suit," Gandhi said.