To the Editor
Although uptake of HIV preexposure prophylaxis (PrEP) is increasing,(1, 2) lower uptake among key HIV risk groups could further increase existing disparities in the HIV epidemic.(3, 4) However, it is unknown whether certain demographic subgroups are underrepresented among PrEP users compared with individuals who recently acquired HIV infection. Thus, we compared demographic characteristics of PrEP users with those of recent HIV seroconverters within the Kaiser Permanente Northern California (KPNC) healthcare system.
KPNC provides comprehensive medical services to 3.9 million members, comprising 46% of insured individuals in the KPNC service area (R. Fong, KPNC Market Strategy and Analysis, written communication, April 2016) and mirroring the demographics of the surrounding population. We included KPNC members who 1) initiated PrEP or 2) acquired HIV infection. PrEP users were those who initiated PrEP after U.S. Food and Drug Administration (FDA) approval (i.e., July 2012–December 2014). Because the demographic composition of those who acquired HIV infection may have changed as high-risk individuals have initiated PrEP, we included HIV seroconverters from the three-year period prior to FDA approval of PrEP (i.e., July 2009–June 2012). Seroconversions were defined as a first lifetime HIV diagnosis at KPNC after a negative HIV test during the three-year pre-PrEP period. Seroconverters were identified using the KPNC HIV registry, and demographic data were collected from the electronic health record. Complete data were not available on transgender identity or HIV-transmission risk factor.
We identified 235 HIV seroconverters and 972 PrEP users (Table 1). Seroconverters were significantly younger than PrEP users (mean age 34.9 vs. 37.9, P<0.001), with 37.9% of seroconverters aged under 30 compared with 25.7% of PrEP users. Nearly all seroconverters and PrEP users were male (98.3% vs. 97.9%, P=0.73). There were differences between HIV se roconverters and PrEP users with respect to race /ethnicity ( P< 0 . 0 0 1 ) ; compared with PrEP users, HIV seroconverters were more frequently Black (23. 6% vs. 4.3% ) or Hispanic ( 19. 7% vs. 12.2%), and less frequently White (45. 9% vs 69. 6%).
Table 1. Demographic differences between those with incident HIV infection and those receiving PrEP, Kaiser Permanente Northern California.
| HIV seroconverters July 2009–June 2012 | PrEP users July 2012–December 2014 | P | |
|---|---|---|---|
| N | 235 | 972 | |
| Age, mean (SD) | 34.9 (10.6) | 37.9 (10.1) | <0.001 |
| Age, % | 0.003 | ||
| ≤29 | 37.9 | 25.7 | |
| 30-39 | 30.2 | 36.0 | |
| 40-49 | 22.1 | 24.8 | |
| ≥50 | 9.8 | 13.5 | |
| Sex, % | 0.73 | ||
| Male | 98.3 | 97.9 | |
| Female | 1.7 | 2.1 | |
| Race/ethnicity, % | <0.001 | ||
| White | 45.9 | 69.6 | |
| Hispanic | 19.7 | 12.2 | |
| Asian/Pacific Islander | 9.2 | 10.3 | |
| Black | 23.6 | 4.3 | |
| Other | 1.8 | 3.6 |
HIV, human immunodeficiency virus; PrEP, preex posure prophylaxis; SD , standard deviation. P-values obtained from chi-square tests for categorical variables and t-tests for continuous variables.
Our results suggest that there may be substantial racial/ethnic and age differences between individuals initiating PrEP and the underlying population at risk of HIV infection, even in a setting with comprehensive access to healthcare . Strategies are critically needed to increase PrEP use in key HIV risk groups with lower PrEP uptake . Without intervention, the underrepresentation of Blacks , Hispanics, and younger individuals among PrEP users may exacerbate existing demographic disparities in the HIV epidemic.
Acknowledgments
JLM has received research grant support from Merck, and MJS has received research grant support from Pfizer and Merck.
This work was supported by a Kaiser Permanente Northern California Community Benefit grant to JLM.
Footnotes
All other authors report no potential conflicts.
Human participant protection: The Kaiser Permanente Northern California institutional review board approved this study with a waiver of written informed consent.
Contributor statement: JLM was responsible for the overall conception and design of the study and obtaining funding. LBH was responsible for collecting and assembling the data. JLM was re sponsible for analyzing the data and drafting the letter. All co-authors were responsible for interpretation of the data, critical revision of the letter, and final approval of the letter.
References
- 1.Volk JE, Marcus JL, Phengrasamy T, Blechinger D, Nguyen DP, Follansbee S, et al. No new HIV infections with increasing use of HIV preexposure prophylaxis in a clinical practice setting. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2015;61(10):1601–3. doi: 10.1093/cid/civ778. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Flash C, Landovitz R, Giler RM, Ng L, Magnuson D, Wooley SB, et al. Two years of Truvad a for pre-exposure prophylax is utilization in the US. Journal of the International AIDS Society. 2014;17(4 Suppl 3):19730. doi: 10.7448/IAS.17.4.19730. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Hess K, Hu X, Lansky A, Mermin J, Hall HI. Estimating the lifetime risk of a diagnosis of HIV infection in the United States. 23rd Conference on Retroviruses and Opportunistic Infections; Boston, Massachusetts. 2016. [Google Scholar]
- 4.Koenig LJ, Hoyer D, Purcell DW, Zaza S, Mermin J. Young People and HIV: A Call to Action. American journal of public health. 2016;106(3):40, 2–5. doi: 10.2105/AJPH.2015.302979. [DOI] [PMC free article] [PubMed] [Google Scholar]