This transcript has been lightly edited for clarity.
Hi, everybody. My name is Lewis Musoke. I’m one of the ID physicians here at the VA [U.S. Department of Veterans Affairs] Northeast Ohio Healthcare System. And I have the privilege to be able to talk to you today about PrEP equity distribution across the VHA [Veterans Health Administration], which is a nationwide cohort integrated health care system.
Why this issue matters: HIV continues to be a problem, not only in the Global South, but also the United States. Over the last decade, we’ve developed different interventions and tools to decrease HIV incidence, and we’ve been able to use these tools—such as oral PrEP or injectable cabotegravir. However, while we’ve seen an increase of these tools globally and nationally, we have noticed that there are specific demographic groups that don’t have the ability to get these active tools of intervention.
The focus of our talk today—and our study—is to delve into what those high-risk populations are, those vulnerable populations, and then really answer the question and lay the groundwork for what can we do moving forward and what strategies can we discuss about addressing these gaps in care.
The first thing is to initially define how we can discuss equitable distribution of PrEP. We use this PrEP-to-Need Ratio, which was first introduced into the HIV scene by Dr. Patrick Sullivan from [Emory University]. He basically described this as the number of patients who are on PrEP compared to the HIV incidence in that specific group. The idea is that higher PrEP-to-Need Ratio is a good thing, showing that you’re able to have a great amount of [the] patients who require HIV prevention on this effective strategy.
However, the reality is we don’t really know exactly what the ideal number is. We can try and extrapolate that, especially as we look into the data more and talk about percentage share of HIV incidence versus percentage share of HIV PrEP uptake. But it is important to start off: Zoom out first, and look, and then focus on what these numbers actually mean moving forward.
We know that, in the calendar year of 2022, if we took a snapshot of a U.S. map and we looked at all the VA [health centers] across the country: We know that on the East Coast and the West Coast—if you could imagine a continuum where dark colors relate to a higher PrEP-to-Need Ratio, lighter colors relate to a lower PrEP-to-Need Ratio—we saw a really good distribution of PrEP uptake in the East and West Coast areas of the United States, as opposed to the South, where we saw some really disparate areas of uptake for PrEP.
When we got into the data more, we started to see more trends— more concerning trends. Nationally, even though we noticed an increase in PrEP-to-Need Ratio across the four years that we were studying, we noticed specifically that white males—and, in fact, white individuals to begin with—had nearly twice as much PrEP access than Blacks. It was not necessarily unique to one specific region of the country; it was certainly seen in all regions, and definitely exacerbated in some more than others, kind of like I alluded to previously, with the map that I was describing with the South showing really the largest disparity in PrEP distribution across these racial and ethnic groups.
So, one might ask: “OK. Now you have all the data. Now you know all these things about PrEP-to-Need Ratio. You have these magical numbers that are flying around across these different demographic groups. What does this mean? What’s the ideal PrEP-to-Need Ratio?”
Truth is, nobody knows. But that’s where the next step comes, which is figuring out a different equation, which is called the percentage share of PrEP and new HIV diagnoses. This is essentially where you look at the amount of PrEP share that a specific group is getting and compare it to the amount of HIV that particular demographic group is exposed to.
When you look at the calendar year of 2022, it was estimated across—nationally, in the VA—that all races other than the Black race had about 61.4% of “HIV shares,” is how we’re calling it to define this, compared to 73.6% of PrEP prescriptions in that particular non-Black population. What that was telling us is they had a higher PrEP share than the HIV incidence in those non-Black populations.
Now, let me turn it around. When you look at the HIV share in Black individuals in calendar year 2022, Black individuals were responsible for 38.6% of new HIV diagnoses. The PrEP share that was accounted in that calendar year was only 26.4%. So, you can see where the disconnect is there.
If you’re looking at a pie diagram and you try to superimpose PrEP share over HIV share, you can see there’s a clear mismatch, in the sense that the non-Black population had a high—relative to the incidence of HIV—had a lot of PrEP share, compared to the Black individuals. This was something that was clear from the PrEP-to-Need Ratio, but very heightened when you look at the PrEP share.
The idea, conceptually, is that you want to be able to create a situation where you have enough PrEP share to cover for the HIV incidence that you’re seeing in a specific demographic group. When we split it up, it was very clear that as you went through the different regions—virtually all regions—Black individuals had much less PrEP share compared to the HIV share. In fact, even more so in the South: Black individuals in the South accounted for 53.5%—over half—of the new diagnoses, but they were only receiving 34.3% of the PrEP share there. That again really highlights the areas of disparity.
When we’ve moved on a little more to focus on gender disparities, we know that our data is not maybe as robust as perhaps other cohorts [due to the demographics of people receiving care in the VA system]. However, we could see that nationally, females’ PrEP-to-Need Ratio was kind of stagnant across the four years [of our study]. And not to belabor the point, but when you looked at the PrEP share to HIV share ratio, the same exacerbations existed, whereby you were seeing female veterans not getting the amount of PrEP that was attributable to their risk of acquiring or having HIV in a particular population.
So, you might ask: “OK, so this is all very depressing, because you’ve told us that we have all these great tools. And now you’ve really honed in; you’ve cut through the data; you’ve focused on specific demographic populations that are having issues with accessing PrEP. So, now, what’s the fix? What can we do about this?”
One thing that was clear with the study is that even in a scenario where you have equal access to PrEP, whereby insurance is not a factor—which, of course, would be a factor in other health care systems—even with that, there were still barriers in which patients were able to get PrEP in our health care system. So what that tells you automatically is that our strategy that we’re using now needs to change. We need to have a more tailored intervention, tailored approach—and probably a more community-engaged approach—where we can find out exactly how we can increase PrEP use in these very vulnerable populations, whether it's from a racial and ethnic or gender minority.
It is important that we continue to aggregate more data as we think about this. And I think, to be honest with you: A study like this, and all the seminal studies that were conducted by Dr. Patrick Sullivan, point towards the fact that we now need a national strategy. We need a national intervention to approach these high-risk populations. And it needs to be not just an integrated approach from one health care system; it needs to be across the board.
Once upon a time, through the tragic story of Ryan White, we were able to develop Ryan White clinics—these are federally-funded clinics that are, to different degrees, able to offer HIV individuals care that they otherwise may not be able to receive without this funding. We need a similar approach, and we need almost a similar aggressive approach, with pre-exposure prophylaxis—and especially with these high-risk groups.
Ultimately, we have the science, we have the data, we have the tools. But now we need the advocacy. And now we need our leaders to wake up and listen to the issues at hand.
