Partnerships between a University-Affiliated Clinic and Community Based Organizations to Reach Black Men who have Sex with Men for PrEP Care

To the Editors

Background

In a recent JAIDS publication by Elopre et al. entitled “The Right People, Right Places, and Right Practices: Disparities in PrEP Access Among African American Men, Women, and MSM in the Deep South,” the authors compared demographic information of patients screened for PrEP care at a university-based clinic in the deep South to those newly infected with HIV in the same community.¹ They showed that patients accessing PrEP clinic services are not the populations most significantly affected by the HIV epidemic; Black persons were markedly underrepresented for PrEP care. In particular Black MSM represented 50% of new HIV cases but only 18% of the PrEP clinic population. Their findings exemplify national trends: 44% of new infections in the U.S. occur in Black persons while only 10% of those prescribed PrEP are Black.² In light of these findings, we report on patient characteristics at our university-based PrEP clinic in the Southeast to demonstrate the value of community partnerships to reach those at greatest risk for HIV infection.

Methods

The Duke PrEP Clinic

We conducted a retrospective cohort study of patients evaluated for PrEP services at Duke University Medical Center’s PrEP Cinic located in Durham, North Carolina (NC). The clinic was established in November 2015 and operates out of the Infectious Diseases clinic. The PrEP Clinic is open one afternoon per week, with other appointment times available for those unable to come during dedicated PrEP clinic hours. Upon presentation to the PrEP Clinic, patients meet a social worker for education and risk reduction counseling. For patients who do not have insurance or funding to obtain access to oral PrEP (emtricitabine/tenofovir disoproxil fumarate), the pharmacy team assists with completion of patient assistance program paperwork for free access to PrEP through the pharmaceutical company. In addition, uninsured patients are linked with discounted services of up to 100% under the Duke University Health System Financial Assistance Policy. Initial visits include discussion of HIV risk, behavioral assessment, screening for sexually transmitted infections, and laboratory testing. In an effort to gain insight on how patients learn about PrEP in our area, we collect information on the source of referral for all patients presenting to our clinic. Patients can be referred by primary care providers (PCPs) within the health system, all of whom have access to electronic referral orders. Alternatively, patients who have heard about our clinic elsewhere can call the scheduling hub themselves at a phone number (“hotline”) specifically created for PrEP appointment booking. Efforts to promote our PrEP clinic have included creation of a clinic website (https://www.dukehealth.org/prepclinic) and blog, an educational initiative for primary care providers (PCPs), advertisements on geosocial networking applications (“dating apps”), postings on social media, and partnerships with community based organizations (CBOs). In particular, we have partnered with CBOs that primarily focus on the health and wellbeing of MSM of color. Through these partnerships, our team attends community events where we promote PrEP with tabling and distribution of educational flyers. All advertisements include the PrEP appointment hotline number.

Data collection

We included all patients seen in the 18 months following clinic opening in our study. We abstracted the following routinely collected variables: age, race, ethnicity, sex at birth, self-identified gender, HIV risk factors and source of referral. Descriptive statistics are presented as medians and frequencies. Race/ethnicity categories included non-Hispanic Black, non-Hispanic White, Latino/Hispanic, and Other. For the purposes of this study, MSM included gay and bisexual men. Referral sources were: CBO, partner seen at our HIV clinic, self-referral (e.g. word of mouth, dating app, or an online search engine), health department, PCP, other provider, or urgent care/emergency department (ED). The Duke University Institutional Review Board determined our study (Pro00079312) to be exempt from further IRB review.

Results

Clinic Population

During the first 18 months following establishment of the clinic, 91 patients were evaluated for PrEP. Of these patients, 90% (n=82) were male according to sex assigned at birth, median age was 31 years old (range 19–66), and 46% (n=42) were non-Hispanic Black, 42% (n=38) non-Hispanic White, and 5% (n=5) Hispanic/Latino. Seventy-eight percent (n=71) were MSM, 3% (n=3) were transgender women who have sex with men (TGW), 9% (n=8) were men who have sex with women, and 10% (n=9) were women who have sex with men. Of the total 91 patients, 30% (n=27) were Black MSM or TGW and 9% (n=8) were Black MSM age <25. Risk factors among all patients included multiple sexual partners (65%), known HIV-positive partner (19%), or a recent sexually transmitted infection (16%). One-quarter of patients were uninsured. In comparison, in NC in 2016, 62% of new diagnoses occurred in Black persons and 40% in Black MSM (Table 1).³

Table 1.

Demographics of Duke PrEP Clinic Patients and New Diagnoses in NC^*

	Duke PrEP Clinic (n=91)	Newly Diagnosed Individuals in NC (n=1399)*
Black - total	42 (46.2%)	869 (62.1%)
Black MSM	27 (29.7%)	562 (40.2%)
Black MSW	8 (8.8%)	117 (8.4%)
Black WSM	7 (7.7%)	177 (12.7%)
White- total	38 (41.8%)	330 (23.6%)
White MSM	37 (40.7%)	248 (17.8%)
White MSW	0 (0.0%)	26 (1.9%)
White WSM	1 (1.1%)	32 (2.3%)
Latino-total	5 (5.5%)	147 (10.5%)
Latino MSM	5 (5.5%)	110 (7.9%)
Latino MSW	0 (0.0%)	18 (1.3%)
Latino WSM	0 (0.0%)	16 (1.1%)
Other-total	6 (6.6%)	53 (3.8%)
Other MSM	5 (5.5%)	29 (2.1%)
Other MSW	0 (0.0%)	5 (0.4%)
Other WSM	1 (1.1%)	16 (1.1%)

MSM: men who have sex with men

MSW: men who have sex with women

WSM: women who have sex with men

^*North Carolina data from 2016

Referral Source

Of patients evaluated for PrEP care, most were self-referrals (n=29). The next most common source of referral was by CBO (n=19), followed by a PCP (n=18). Among Black patients, the most common source of referral was CBO (n=17, 40%), followed by self-referral (n=7, 17%). Only three Black patients had been referred by a PCP. Black MSM and TGW were most commonly referred by a CBO (n=12, 44%). Among White patients, most were self-referrals (n=18, 47%) or were referred by a PCP (n=12, 32%). Few patients were referred by the health department (n=5) or the ED/urgent care (n=2).

Discussion

Our retrospective cohort study revealed two important findings. First, patients evaluated for PrEP at our clinic are more representative of the national HIV epidemic as compared to all PrEP users in the US. Our initial patient numbers, while limited, are promising: roughly half of our patients are Black, including 30% Black MSM. Second, the most common referral source for Black and Black MSM patients was through CBOs, demonstrating that community partnerships can be a valuable avenue for patient recruitment. While large-scale efforts are needed nationwide to improve PrEP awareness and linkage to care, we believe that CBOs can play a critical role in reaching populations at high risk with messages about PrEP.

As Elopre et al. note, the burden of HIV is especially great in the South.^1,4 Underscoring this fact, the HIV prevalence of MSM in our region, the Durham-Chapel Hill metropolitan statistical area (MSA), ranks 12^th highest among all MSAs nationwide (17.5 per 100).⁵ Elopre and coauthors also discuss racial disparities related to HIV that are especially prominent in the South. Of all Black MSM diagnosed with HIV nationally in 2015, 64% percent were living in the South.⁴ In North Carolina, a non-Medicaid expansion state with one of the highest HIV diagnosis rates, Blacks represented 62% of all adult/adolescent diagnoses in 2016, and the highest rate of new infections—81.0 per 100,000—was among adult and adolescent Black males.⁶ If current trends continue, disparities in achieving HIV protection with PrEP have the potential to exacerbate racial disparities already seen with HIV infection.⁷

Cognizant of the detrimental public health impact of HIV in our region but motivated by the promise of PrEP to prevent transmission, we established our dedicated PrEP clinic and began engaging in community partnerships and efforts to raise awareness about PrEP in our community. Our data indicate that a successful strategy to reaching Black MSM with messages about PrEP is partnering with CBOs. Prior research has demonstrated that partnerships with CBOs are valuable in recruiting Black MSM for HIV preventative clinical trials,⁸ although little work has focused on partnerships with CBOs to recruit for PrEP clinical care. More than forty percent of Black MSM and TGW in our clinic were referred by CBOs, entities that play a critical role in promoting PrEP among persons of color and without which our clinic would see significantly fewer of these patients. One reason for the success of CBOs in our community may be the provision of navigators who assist patients in overcoming structural barriers to PrEP engagement (e.g. lack of transportation for clinic visits). Further research and programmatic support should be granted to CBOs to help them reach the population most affected by HIV in the South. Elopre et al.¹ suggest that increasing awareness through community-based support systems is needed, and our study provides preliminary data to support this recommendation.