Public awareness of HIV pre-exposure prophylaxis in Durham, North Carolina: results of a community survey

Abstract

Background:

Adoption of HIV pre-exposure prophylaxis (PrEP) remains limited among populations at greatest risk for HIV acquisition. This study aims to assess awareness of PrEP among individuals in Durham, North Carolina (NC), which has one of the highest rates of HIV diagnoses in the state.

Methods:

In 2015-2016, we administered a survey including questions to assess PrEP awareness to individuals at multiple venues throughout Durham.

Results:

A total of 139 respondents were surveyed. The majority were male (66%) and black/African American (75%); 21% were Hispanic/Latino. There were an estimated 53 men who have sex with men (MSM), of which 18 (33%) were black MSM ≤24 years of age. Overall, only 53/138 (38%) respondents were aware of PrEP. Awareness was reported among 33/52 (63%) MSM respondents, 29/46 (63%) black MSM, and 10/17 (59%) black MSM ≤24 years of age. In multivariate analysis, non-heterosexual orientation, health-insured status, and prior HIV testing were significantly associated with PrEP awareness. Ninety-four (69%) of 137 respondents reported prior HIV testing.

Limitations:

Limitations include non-random sampling and limited sample size. Further research needs to be done in other areas of NC, and assessment of PrEP acceptability and uptake needs to be performed.

Conclusions:

This study reveals low overall awareness of PrEP in Durham, NC, indicating that expanded outreach is necessary to increase public awareness and encourage adoption of PrEP among all demographics at risk for HIV.

INTRODUCTION

Despite significant advances in human immunodeficiency virus (HIV) treatment, the burden of HIV in the United States (US) remains persistently high with approximately 40,000 newly diagnosed infections each year [1]. The number of annual HIV infections attributed to male-to-male sexual contact has increased over the past decade, particularly among racial/ethnic minority young men who have sex with men (MSM) [1,2]. Young black MSM (YMSM) aged 13-24 years are now the most severely affected subgroup of MSM, with over 3,500 new HIV infections attributable to male-to-male sexual acquisition among black adolescents and young adults in 2015 [1]. Geographically, the South bears the highest HIV burden out of any US region, accounting for approximately half of all new infections in the US in 2015 [1]. At the intersection of these attributes, young black MSM living in the US South represent a population that is especially vulnerable to HIV infection [1].

HIV pre-exposure prophylaxis (PrEP) is now established as a safe and efficacious strategy to reduce HIV transmission among high-risk individuals [3-7]. Following FDA approval of daily oral emtricitabine/tenofovir disoproxil fumarate for PrEP in 2012, the US Public Health Service released comprehensive clinical practice guidelines in May 2014 for use of PrEP, identifying MSM as a priority candidate population [8]. Actual utilization of PrEP, however, has remained limited [9,10]. One study of MSM across 20 US cities found that only 4% were using PrEP in 2014 [11]. Moreover, disproportionately low rates of PrEP use among racial/ethnic minority MSM have been observed in multiple settings [9,11-13].

Despite the substantial HIV burden in the US South, public awareness of PrEP in this region remains poorly characterized. In this study, we conducted a survey of individuals in Durham, North Carolina (NC) to evaluate awareness of PrEP.

Methods

Setting

Durham County is an urban community located in central NC and is part of the Durham-Chapel Hill, NC Metropolitan Statistical Area. Of US states, NC had the eighth highest number of new HIV diagnoses in 2015 [1]. The rate of new HIV diagnoses in Durham was 20.3 per 100,000 population in 2015, compared to statewide and national HIV diagnosis rates of 13.4 and 12.3 per 100,000 population, respectively [1,14]. Of 100 NC counties, Durham ranked fifth highest in newly diagnosed HIV three-year average rates among adults and adolescents in 2014-2016 [15].

Recruitment

A self-administered survey was conducted in 2015-2016 as part of a county-wide HIV testing and awareness initiative (“Durham Knows”) implemented by the Durham County Department of Public Health and the Partnership for a Healthy Durham. Purposive sampling was performed to obtain a diverse sample of participants, who were recruited from a college campus; a Hispanic/Latino community center; a group housing community center; a community health center for the medically underserved; a public Kwanza celebration; and a community organization serving the African American and Latino lesbian, gay, bisexual, and transgender communities. Paper-based surveys were offered in English and Spanish. Participants were not compensated for their participation.

Measures

The questionnaire was developed by the authors and translated into Spanish by a formal translation service. Key survey questions included the following:

Demographics:

Participants were asked to report their age, gender, race/ethnicity, health insurance status, highest completed education level, and sexual orientation. As the survey did not explicitly include questions about sexual behavior, respondents identifying as both male and either homosexual/gay or bisexual were categorized as MSM. Respondents of ages 24 and under within the ‘MSM’ category were considered young men who have sex with men (YMSM). Multi-racial MSM identifying as part black/African American were considered black MSM, and those identifying as part Hispanic/Latino were considered Latino MSM.

HIV perceptions:

Participants were asked to indicate their level of agreement to a series of statements regarding HIV. Only those responding “yes” were considered to have an affirmative response.

HIV testing:

Participants were asked to report whether they knew where to get tested for HIV, hepatitis, and other sexually transmitted diseases (STDs); whether their doctor had ever offered them an HIV test; and whether they had ever been tested for HIV.

PrEP awareness:

PrEP awareness was assessed with the question, “Do you know if there is a pill that can prevent a person from getting HIV?” Those who responded “yes” were considered to be PrEP aware.

Survey questions are available in Appendix 1.

Data analysis

Data was analyzed in R v3.3.1 (Vienna, Austria) using RStudio (Boston, MA). All respondents were included in the analysis. Denominators used to calculate simple proportions represent the number of respondents who answered each survey question; missing responses were omitted from the analysis. Bivariate comparisons were conducted using Fisher’s exact test. Logistic regression was performed on the following candidate predictors of PrEP awareness: gender, age >24 years, sexual orientation, black/African American race, health insurance status, post-secondary education, and prior HIV testing. Forward and backward selection methods were used to obtain a final multivariate model. Two-tailed p-values were used; alpha of 0.05 was used to define statistical significance. Nine respondents received surveys that were missing one page containing questions to assess HIV perceptions. These respondents were included in the analysis of all other questions.

Ethics statement

This study was reviewed and approved by the Institutional Review Board (IRB) at University of North Carolina at Chapel Hill and was approved as an IRB research exempt protocol at Duke University. No personal health information or identifiers were collected in the survey.

Results

Respondent characteristics

A total of 139 respondents participated in the survey. Of these, 117 completed the English version and 22 completed the Spanish version. The median (range) age was 28 (14-73) years. Based on self-reported homosexual/gay or bisexual orientation, the respondents included an estimated 53 MSM, 47 black MSM, and 18 black YMSM. Demographic characteristics are summarized in Table 1.

Table 1.

Demographic characteristics of survey participants (N=139).

Characteristics	% (n)
Gender (9 missing)
Male	66% (86)
Female	31% (40)
Transgender	3% (4)
Age (18 missing)
24 years or younger	42% (51)
25 years or older	58% (70)
Sexual orientation (13 missing)
Heterosexual or straight	49% (62)
Homosexual, gay, or lesbian	29% (37)
Bisexual	13% (16)
Transgender	3% (4)
Not sure or other	6% (7)
Race/Ethnicity (9 missing)
Non-black, non-Latino	7% (9)
Black or African American*	75% (97)
Latino or Hispanic*	21% (27)
Education (10 missing)
Did not graduate from high school	15% (19)
High school graduate or GED	36% (46)
Some college/associate degree/technical school	28% (36)
Bachelor’s degree	16% (21)
Post-graduate degree	5% (7)
Health insurance (10 missing)
No insurance	30% (39)
Private insurance	29% (37)
Medicaid or Medicare	28% (36)
TRICARE or military insurance	13% (17)
HIV testing status (2 missing)
Have been HIV tested	69% (94)
Have not been HIV tested	31% (43)

^*Includes 3 participants identifying as both Black/African American and Latino/Hispanic

One hundred and four (76%) of 136 respondents reported knowing where they could get tested for HIV and other STDs. Eighty-two (59%) of 138 reported ever having been offered an HIV test by their doctor, while 94 (69%) of 137 respondents reported ever having been tested for HIV. Respondents’ perceptions regarding HIV are summarized in Table 2.

Table 2.

Participants’ perceptions regarding HIV, Durham, North Carolina, 2015-2016 (N=130).

Characteristics	% (n)
Belief that condoms reduce risk of HIV	80% (102/128)
Self-reported knowledge of how to protect oneself from HIV	74% (92/124)
Belief that people with HIV can appear healthy	63% (81/128)
Belief that HIV is treatable	62% (76/123)
Belief that stigma plays a role in whether one gets treated for HIV	61% (75/122)
Belief that stigma plays a role in whether one gets tested for HIV	60% (74/123)
Fear of others knowing if one is getting HIV tested	31% (38/123)

Questions were omitted for 9 respondents; varying denominators reflect missing data for the 130 participants asked to answer these questions.

PrEP awareness

Of the entire sample, 53 (38%) of 138 respondents reported awareness of PrEP. This included 33 (63%) of 52 MSM respondents, 29 (63%) of 46 black MSM, 10 (59%) of 17 black YMSM, 5 (71%) of 7 Latino MSM, and 3 (75%) of 4 Latino YMSM. Overall, MSM respondents had significantly greater odds of reporting PrEP awareness compared to other respondents (OR 5.6, 95% CI 2.5 – 13.1).

In univariate logistic regression analyses, male gender, non-heterosexual orientation, health-insured status, and a history of prior HIV testing were significantly associated with greater odds of PrEP awareness. There were no significant differences in PrEP awareness among black/African American respondents compared to non-black respondents, respondents ≤24 years of age compared to older respondents, or respondents with post-secondary education compared to those without post-secondary education. In multivariate regression analysis, a final model was obtained which included sexual orientation, health insurance status, and history of HIV testing as significant predictors of PrEP awareness (Table 3).

Table 3.

Univariate and multivariate regression analyses of factors associated with PrEP awareness among individuals in Durham, North Carolina, 2015-2016 (N= 112).

Forward and backward selection methods produced the same final multivariable model. The other candidate variables were gender (p<.05 in the univariate model but not the multivariate model), age, race, and education.

Characteristics	PrEP aware n (%)	Univariate OR (95% CI)	Multivariate OR (95% CI)
Sexual orientation
Heterosexual	12/56 (21.4)	ref	ref
Non-heterosexual	33/56 (58.9)	5.3 (2.3 –12.5)	5.6 (2.3 – 1.42)
Health insurance
Uninsured	7/29 (24.1)	ref	ref
Insured	38/83 (45.8)	2.7 (1.1 – 7.3)	3.4 (1.2 – 10.6)
HIV testing status
Never tested	6/33 (18.2)	ref	ref
Tested	39/79 (49.4)	4.4 (1.7 – 12.8)	3.6 (1.3 – 11.4)

Respondents who believed that HIV is treatable (OR 2.2, 95% CI 1.0 – 5.1) or that condoms reduce the risk of acquiring HIV (OR 2.7, 95% CI 0.9 – 8.8) were more likely to report awareness of PrEP. Those who reported belief that stigma affects HIV testing (OR 2.1, 95% CI 0.9 – 4.8) or that stigma affects HIV treatment (OR 2.6, 95% CI 1.1 – 6.3) were also more likely to report awareness of PrEP. There was no significant association between self-reported knowledge of how to protect oneself from HIV with PrEP awareness (OR 1.8, 95% CI 0.7 – 4.8).

Discussion

There is a growing body of evidence demonstrating the effectiveness of PrEP in prevention of HIV acquisition. Unfortunately, despite CDC recommendations that PrEP be offered to sexually active adult MSM and heterosexually active individuals at risk of HIV acquisition [8], rates of PrEP adoption remain low across the US [16]. Few other studies have examined PrEP awareness and use specifically in the South [17-20]. Our findings reveal low overall PrEP awareness in an area of relatively high HIV incidence, despite our sample including community organization members and community health center clients who would be expected to have access to HIV prevention messages. This finding reflects a need for increased community education on PrEP use and HIV prevention among target groups.

MSM represent a high-priority population for PrEP provision. PrEP awareness among gay and bisexual men in our study was fairly high with nearly two-thirds reporting awareness, reflecting trends towards increased PrEP awareness among MSM over the past several years [20-22]. However, considering the substantial benefit that MSM are likely to receive from PrEP, future efforts to increase PrEP knowledge and uptake should still incorporate dedicated outreach towards this population.

We found lower rates of PrEP awareness among individuals who lacked health insurance, which could reflect lower utilization of routine preventive services [23]. As the scale-up of PrEP proceeds, careful consideration is necessary to implement strategies that are inclusive of those with limited access to preventative services. Such strategies may include educational initiatives for health care providers who serve the uninsured and underinsured populations, as well as support for local health departments and community health centers in community education, linkage to care, and direct provision of PrEP-related care [24].

Concerns have been raised about the underrepresentation of black/African American populations and other racial/ethnic minorities in PrEP awareness, access, and utilization [11-13,18,25,26]. Interestingly, racial/ethnic disparities in PrEP awareness were not observed in our sample. The lack of observed difference could possibly be an artifact of sampling bias, as surveys were distributed at multiple venues dedicated to health promotion among minority groups. Regardless of these findings, the disproportionately high rates of HIV infection among minority populations, in particular black and Latino MSM, necessitate targeted outreach towards these at-risk groups.

This study is not without limitations. While sample selection was intended to achieve a demographically diverse sample, recruitment of participants from a clinical site could have resulted in a study sample with increased health utilization compared to the overall Durham population. Additionally, Durham represents an urban/suburban environment with likely higher overall access to health information compared to rural North Carolina or elsewhere in the southern United States. The rates of PrEP awareness observed in this sample therefore may not be generalizable to all individuals in Durham, North Carolina, or the South. Further research is therefore still needed to characterize PrEP awareness and knowledge in other settings throughout the South. Our study also included a limited sample of Hispanic/Latino respondents, for whom dedicated research is needed. Finally, respondents were not assessed for specific knowledge about PrEP, willingness to adopt PrEP, or actual PrEP use. These questions should be addressed in future research on PrEP implementation in this population.

In conclusion, the low rates of PrEP awareness in this study highlight an urgent need for expanded PrEP outreach to increase utilization among individuals at high risk for HIV acquisition in NC. Since the survey was conducted, several programs have been developed at the local public health department and adjacent academic centers to increase public awareness of PrEP. Concerted efforts should be continued among health care providers and public health leaders statewide to promote interest and ensure equitable access to this potentially life-saving HIV prevention strategy.