A shot at equity? Addressing disparities among Black men who have sex with men in the coming era of long-acting injectable pre-exposure prophylaxis

Pre-exposure prophylaxis (PrEP) has great potential to curb the HIV epidemic among men who have sex with men (MSM) in the United States [1]. However, persistent inequities in use between Black and White MSM [2] may exacerbate existing incidence disparities [3, 4].

Black MSM experience significant social and structural barriers to PrEP use [5]. For example, physicians are less likely to prescribe PrEP to Black MSM as they are perceived to be more likely to forego condom use upon initiation [6]. These moralistic judgments are closely tied to race-based sexual stereotypes, where Black men are perceived as promiscuous and hypersexual [7]. Limiting access based on anticipated sexual behaviors is not scientifically justifiable. These biases may lead Black MSM to feel that they do not have agency in medical decision-making and culminate in lower PrEP use [8]. Healthcare systems need to acknowledge that these biases exist, and take steps to actively address them [9]. When culturally competent PrEP programs are designed by and for Black MSM, they can and do benefit from using the medications [10].

With recent trials demonstrating efficacy of long-acting injectable antiretroviral treatment [11] and an ongoing efficacy trial for long-acting injectable PrEP (LAI-PrEP) expected to conclude in 2022 [12], LAI-PrEP holds promise as another effective HIV prevention option. LAI-PrEP may be an attractive method for MSM who have used PrEP but have challenges adhering to daily pill taking [13, 14]. Some MSM fear being perceived to be gay, promiscuous, or HIV-positive if seen taking PrEP; as such, LAI-PrEP may be attractive for those concerned with such stigma given its more discreet nature [5, 8]. However, medical mistrust remains a unique barrier to engagement with HIV prevention among Black MSM [15], and although studies are not representative of all Black MSM, research indicates that this barrier can be overcome when providers can build trust and address potential suspicions [16].

Potential Pitfalls: Learning from Other Long-Acting Injectable Medications

Little is known about approaches to optimize LAI-PrEP implementation to reduce disparities. It is possible that use among this population will mirror low uptake of PrEP [2]. Implementation of long-acting reversible contraceptive (LARC) methods for family planning and long-acting antipsychotics in mental health care offers important lessons about how injectable technologies may impact disparities ^[17]. Health care providers are more likely to offer LARC methods and long-acting antipsychotics to Black patients ^[18–22], as they may be perceived to be at high risk for non-adherence ^[23]. Rather than deploying methods to encourage and support adherence to oral medications, the insistent offering of a long-acting medication may lead to medical mistrust and perceptions that these medications are being used as a form of paternalistic control ^[24]. Should evidence support the use of both modalities, patients’ decisions to initiate one method over the other should be based on their preferences, needs, and desires rather than stereotypes and implicit biases. Clinical support, including ongoing provider education, is needed to build climates of cultural competence where providers have the skills to build trust and patients are empowered to control over decisions impacting their health [25].

With multiple forms of PrEP potentially available in the coming years, which modality a man uses has important implications for how successful he will be in preventing HIV infection. Men should be free select modalities that optimize effectiveness and ease of use rather than on the basis of logistical considerations (e.g., insurance coverage and ability to pay). Failure to do so may result in disproportionate uptake among White MSM in a manner mirroring PrEP [2]. Drawing on the literature on contraceptive choice ^[26], further research is needed to understand method acceptability, comparing what men say they value in a modality with the attributes of these products. These values may differ for Black MSM ^[27], so it is essential that research and care center on the needs and experiences of these communities to address inequities.

Summary

There is tremendous opportunity to narrow racial disparities in HIV incidence with the introduction of new prevention products like LAI-PrEP, but their success in achieving this goal will depend on whether the social and structural barriers to their use that disproportionately impact Black MSM can be overcome. Robust, multi-pronged interventions are needed to improve access and promote persistence. A public health agenda that centers on the experiences and needs of Black MSM is urgently needed to address the root causes of these disparities, while ensuring that multiple prevention modalities are deployed without bias and at levels commensurate with epidemiologic need.