Expert Q&A

Disparities in Uptake and Use of PrEP

Despite public health initiatives aimed at preventing the spread of HIV and increasing access to pre-exposure prophylaxis (PrEP), health care disparities continue to exist along the care continuum for certain patient populations, such as young adults, transgender individuals, and cisgender women. Therefore, it is essential for health care providers to be diligent in creating and maintaining strategic interventions to ensure the access and use of PrEP in these patients.

This was the topic of discussion presented by Monica Gandhi, MD, MPH, at the International Antiviral Society-USA’s 2021 conference. As a follow-up to this session, Consultant360 asked Dr Gandhi more about the applications and implications of her research.

Dr Gandhi is a professor of medicine and the associate division chief of the Division of HIV, Infectious Diseases, and Global Medicine at the University of California San Francisco.

Consultant360: Could you start with giving us a brief overview of your session and the learning objectives?    

Dr Gandhi: This session was meant to go over racial and ethnic disparities in PrEP uptake across the US population, as well as PrEP disparities in uptake for youth and cisgender women. The session also discussed problems with PrEP persistence (staying on PrEP) among these populations, including a focus on transgender populations. The session then went over interventions that can help improve PrEP uptake and persistence among racial/ethnic minority communities, including community-based messaging, culturally appropriate programming, and considering long-acting PrEP with intramuscular cabotegravir every 8 weeks. We discussed some of the data around the different PrEP options, including injectable PrEP, and ended with a call to action on addressing these disparities.

C360: You mentioned in your session that racial, ethnic, and gender disparities exist, not only for initiating PrEP, but also along the entire PrEP care continuum. What stages along the patient’s journey do you think should be targeted for intervention to have the most impact on improving outcomes and access? 

Dr Gandhi: Yes, disparities in PrEP begin with PrEP awareness and continue through uptake, persistence, and adherence to PrEP. I think the most effective interventions we can make is to increase information about PrEP in marginalized communities and then, eventually, helping to support patients on staying on PrEP and adhering to this important intervention. There are a number of adherence interventions that work, including the use of pill boxes, motivational counseling, and monitoring adherence with objective metrics. These should be applied widely to populations with disparities in PrEP use.

C360: What factors should providers consider when determining intervention strategies in their communities or patient populations?

Dr Gandhi: The factors we should consider when determining intervention strategies in different communities or patient populations include youth-focused efforts with messaging to youth and youth PrEP navigation. We also suggest support for pharmacy-led PrEP programs, which have been codified in California after a state law; social media campaigns to raise awareness in various communities; Truvada emergency funds; and provider detailing and training of multiple types of providers such as primary care, urgent care, emergency room providers, to discuss PrEP with patients. We also suggest public dashboards on PrEP uptake in various communities to help raise awareness. And finally, making PrEP easier with express visits, telemedicine, and on-demand PrEP care sites around the country. 

C360: What are some common pitfalls to avoid when maintaining or addressing problems with access and use of PrEP among various hard-to-reach populations? 

Dr Gandhi: One common pitfall is to adopt a one-size-fits all approach where we use the same messages on all communities. We need targeted messages in hard-to-reach communities by trusted community messenger to expand PrEP in these populations. 

C360: You also noted in your session that health disparities among cis-gendered women and older adults are often overlooked or underrepresented in the literature. How would a patient journey for these populations differ compared with other populations? 

Dr Gandhi: Yes, these are groups that are particularly neglected in our PrEP messaging, particularly because the general perception is that they are less at risk. We need to study these populations better to understand their level of risk and, again, use targeted messaging to help them uptake and adhere to PrEP moving forward.    



Gandhi M. How to reach the hard to reach: policies and strategies to address access to PrEP. Presented at: IAS-US 2021; November 19, 2021; Virtual. Accessed April 19, 2022.