Aaron Siegler, PhD, MPH, is an Associate Professor in the Department of Behavioral Sciences and Health Education at Emory University’s Rollins School of Public Health.
Q: Newly released data from your paper, “Policy and County-Level Associations with HIV Preexposure Prophylaxis Use, United States, 2018” published in Annals of Epidemiology, found that Medicaid expansion and/or the existence of a Pre-Exposure Prophylaxis Drug Assistance Program (PrEP-DAP) were associated with higher PrEP use in states. Why do you think that is and how can policymakers, public health officials, and community organizers use these findings to increase PrEP access?
From a public health perspective, there are a number of barriers to access associated with PrEP. Since PrEP is a biomedical intervention there are required clinical visits and routine laboratory tests that are needed to receive a prescription. In addition, you have to factor in the cost of the medication itself and associated health care services – all of which act as barriers to access for many communities.
Financial assistance programs are one way of lessening the affordability barrier associated with PrEP. For example, the manufacturer has assistance programs that largely cover the cost of medication, but people are often unaware of this. But there are also additional costs associated with PrEP like the ongoing clinician visits and laboratory tests. This is why Pre-Exposure Prophylaxis Drug Assistance Programs (PrEP-DAP) and Medicaid expansion can help people not only cover the costs of the medication if needed but also the other costs of PrEP care.
I think these programs allow people to have self-efficacy – or the belief that they can overcome a barrier. In this case, the affordability barrier. Having assistance programs available helps people understand that, “Hey, this is something that I can do.” The health behaviors that we have as people are influenced by the world around us. The job of public health professionals, the government, and community organizations should really be to help people reach those health decisions that are best for them. It’s very encouraging that programs like PrEP-DAPs and policies like Medicaid expansion are associated with increased PrEP use.
Q: Expanding national access to PrEP medications is a key component of the federal Ending the HIV Epidemic: A Plan for America (EHE) initiative. How has PrEP usage changed over time, and what can we learn from these patterns?
PrEP use has substantially expanded over time in the United States. In fact, we have a simple majority of the world’s PrEP users, which is exciting. But we still have a way to go. Our analysis found that PrEP use has grown by 39% from 2017 to 2018, and there were approximately 235,000 PrEP users in 2018. Our dataset included a total of 188,546 PrEP users nationally. A sensitivity analysis was conducted to account for missing data and identified that a national best estimate of all PrEP users was 235,683, with a range of 188,546-269,351 PrEP users. (see methods on how this number is derived here) While this is an encouraging number, our paper identified a national trend that PrEP use is not necessarily scaling up evenly relative to the epidemic need. For example, we see women and younger persons are receiving less PrEP use relative to their epidemic burden. These are the disparities that we need to identify and figure out how to address through interventions so we can keep the expansion of PrEP on the right trajectory overall.
Q: The Centers for Disease Control and Prevention (CDC) has estimated that approximately 1.1 million people are at high risk for HIV exposure and could benefit from comprehensive HIV prevention strategies, including PrEP. What are some of the key barriers that limit access to PrEP and other HIV prevention services?
In addition to the financial barriers we discussed earlier, there are also the logistical barriers of finding a nearby PrEP provider. We’ve seen that geographic access to PrEP providers can be a huge barrier to care for many rural populations. One of the useful tools is our affiliate site, preplocator.org, where individuals can go to find a PrEP provider near them.
Stigma is another barrier. There is substantial stigma against HIV itself, as well as the medications used to treat HIV and preventive interventions such as PrEP. In contrast to this stigma, in my research people on PrEP describe a lot of benefits. Those using PrEP often describe being able to live their lives free of worry about HIV, feeling positive about their health, and feeling proactive about their health. They also recognize that being on PrEP is part of a solution to protect their entire community, as well as future generations.
I think if we want to combat stigma about HIV and PrEP, we also have to reinforce these positive aspects of PrEP. This is an issue where we need to tackle both sides of the coin to make it clear that there are fantastic aspects of PrEP that provide tangible benefits to people who are taking it, while also directly addressing the stigma that exists.
Q: Your analysis revealed that counties with a higher concentration of Black residents, counties with higher levels of non-insured residents, and counties whose residents had lower levels of education also had lower levels of PrEP use relative to their need for PrEP. What can we learn from this finding, and why do you think it is critical for informing local strategies?
These findings illustrate that that PrEP is not scaling up evenly across the United States and shows the important disparities across different sexes, age groups, geographic regions, and those with lower access to care. When you map this data, you can see the significant geographic variation that exists – which is not random.
When mapping this PrEP use data, we see a lot of overlap with factors that are associated with access to other health services: insurance coverage, poverty, and race. For example, our research also found that the counties with the lowest proportion of Black residents had PrEP use rates when compared to epidemic need (as determined by number of new cases), that were twice as high compared to counties with the highest proportion of Black residents –a huge disparity. To increase PrEP use in Black communities, the public health community must develop programs to address the factors driving these disparities, like medical mistrust or a lack of awareness about available HIV services.
To end the HIV epidemic we need to make sure public health care workers are aware of the existing gaps in care services that often require additional attention, services, and resources. This is why it is so important to identify these disparities at the local level – so they can be addressed properly through innovative interventions and evidence-based practice. In our research, we found that policies that promote PrEP are associated with higher PrEP use. While this sounds obvious, this is an encouraging finding because it means there are known interventions that are associated with higher PrEP use. This should inspire both researchers and activists to double down on bringing about change regarding facilitating access.
Q: AIDSVu recently added interactive state and county level maps visualizing PrEP use from 2012 through 2018. What are some ways that AIDSVu users can use these data and maps to better understand and respond to the HIV Epidemic?
I think mapping tools are inherently powerful. They can help people visualize the way that PrEP is being used in their communities. They allow us to quickly understand the data over time and see into our specific communities. The goal of visualizing this research is to empower these stakeholders by giving them tools to see PrEP use at the local level and hopefully begin to develop policies to increase PrEP awareness.
In addition, visualizing disparities will help policymakers and health care workers identify these access disparities, so they know which areas to direct the needed resources to properly address these service gaps. Ultimately, I hope these data and resources will allow users to communicate what is happening with PrEP in their communities, the progress to date, trends in PrEP use, and help plan for the next steps in promoting PrEP in their communities.