Engaging United States Black Communities in HIV Pre-exposure Prophylaxis: Analysis of a PrEP Engagement Cascade

Background/Purpose: National PrEP utilization analyses show US non-Hispanic Blacks accessing PrEP at disproportionately low rates given the higher HIV prevalence among Blacks, and in comparison to utilization by non-Hispanic Whites. Women also are underrepresented among PrEP utilizers, especially Black women. We examine the process of accessing PrEP for a majority Black population in an urban community health center setting. Methods: In the Philadelphia city health centers, patients referred for PrEP were followed through six steps of accessing PrEP: referral, patient contact by a PrEP team, maintained interest by patients, scheduling of screening appointments, attending screening appointments, and initiating PrEP. Chi-squared tests were performed at each stage to identify gender differences in drop-off at each step. Results: Between August 2014 and December 2015, 14% of 785 patients referred for PrEP initiated. Women constituted 37.8% of referrals. A smaller majority of Blacks initiated (84.6% of females, 69.5% of males) than were referred (94.5% of females, 88.1% of males). Prior knowledge of PrEP was associated with screening (68% of those with prior knowledge screened, compared with 29.6% of those without prior knowledge,X2 p<0.0001). Higher initiation: referral ratios were noted for self-referrals, and for those referred by clinicians, peers and partners. Conclusions: In a diverse cohort in a community health center setting, myriad barriers resulted in a 14% initiation rate for persons at elevated risk for HIV who were referred for PrEP. These barriers led to disproportionately fewer non-Hispanic Blacks and women initiating PrEP. Efforts to better engage Blacks and women in PrEP care are urgently needed, and may include better dissemination of PrEP-related information in Black communities and to women, and training of clinicians serving Black and female populations to improve competency in provision of PrEP care.