PrEP indicates preexposure prophylaxis.
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Khanna AS, Michaels S, Skaathun B, et al. Preexposure Prophylaxis Awareness and Use in a Population-Based Sample of Young Black Men Who Have Sex With Men. JAMA Intern Med. 2016;176(1):136–138. doi:10.1001/jamainternmed.2015.6536
In the United States, reducing new human immunodeficiency virus (HIV) infections will require a determined focus on primary HIV prevention among young black men who have sex with men (YBMSM), the only group in the United States where HIV incidence has increased over the past decade.1 Through 2011, effective clinic-based HIV prevention interventions that target YBMSM have been virtually nonexistent.2 In 2012, the US Food and Drug Administration approved a preexposure prophylaxis (PrEP) consisting of daily oral tenofovir disoproxil fumarate and emtricitabine. This PrEP has an estimated effectiveness of over 90%3 and, therefore, an HIV prevention effect potential for several domestic HIV epicenters.4
The south side of Chicago represents the largest contiguous black community in the United States. Despite the many assets of the south side, this community has a high HIV prevalence. uConnect is a population-based cohort study of YBMSM that examines how sociodemographic, health, behavioral, and social factors drive new methods of HIV prevention, including PrEP.
Using respondent driven sampling (RDS), 622 eligible YBMSM were recruited between June 2013 and July 2014. Study participants were eligible to be interviewed if they (1) self-identified as African American or black, (2) were born male, (3) were between 16 and 29 years of age, and (4) reported oral or anal sex with a male within the past 24 months. The sample was weighted using general probability estimates5 using the RDS package in R (R Foundation). We examined the relationship of a set of sociodemographic, health care engagement, behavioral, and social characteristics with PrEP awareness and uptake.
A final analytic sample of eligible participants (n = 622) was generated through RDS chains of up to 13 waves in length and with a median of 2 recruits per participant. The mean (SD) age of the sample was 22.7 (3.2) years. Approximately 39% of participants had high school– or general education development–level terminal education, and 79.3% reported an income of less than $20 000 per year. Nearly half (48%) of HIV-negative (PrEP-eligible) individuals reported having either some government or private health coverage.
At baseline, PrEP awareness among uConnect participants was 40.5%, and 12.1% knew others who had used PrEP. PrEP awareness remained relatively stable over the recruitment period (Figure). Approximately 72.1% of the sample was not infected with HIV, 3.6% of whom had used PrEP. Having a primary care provider, participating in an HIV prevention program or research study, having had an anorectal sexually transmitted infection test, and membership in the House and Ball community, a national network of socially organized “houses” largely comprised of YBMSM and transgender women that has existed in Chicago since the 1930s, were significantly associated with PrEP awareness (Table). Additionally, among PrEP-eligible participants, meeting with an HIV outreach worker within 12 months of being recruited to our uConnect cohort was significantly associated with PrEP awareness (adjusted odds ratio [aOR], 2.02; 95% CI, 1.29-3.16).
uConnect is the first study of diverse YBMSM-relevant characteristics and corresponding PrEP engagement from a population-based sample. Low PrEP awareness and uptake among YBMSM parallels earlier HIV treatment disparities. While PrEP is promising, this population-based cohort study illustrates that real-world PrEP use by those with the highest HIV incidence faces major implementation challenges that require purposeful and sustained engagement with black communities inclusive of their health care providers. We find that PrEP awareness is associated with a diverse range of clinical engagement activities among YBMSM. The Affordable Care Act (ACA) represents one potential opportunity to increase such clinical engagement. However, ACA benefits are not recognized in all regions of the United States, and in our cohort, only half of the participants had any type of health care coverage. Ongoing work should include scientific assessment of strategies to mobilize networks of YBMSM around PrEP as part of a comprehensive health care program. Concomitantly, efforts to mitigate the structural barriers that prevent PrEP uptake among YBMSM may greatly improve the public health effect potential of this promising HIV prevention intervention.
Corresponding Author: John A. Schneider MD, MPH, Associate Professor, Medicine and Epidemiology, Section of Infectious Diseases and Global Health, Departments of Medicine and Public Health Sciences, University of Chicago, 5837 S Maryland Ave, MC 5065, Chicago, IL 60637 (firstname.lastname@example.org).
Published Online: November 16, 2015. doi:10.1001/jamainternmed.2015.6536.
Author Contributions: Dr Schneider had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Khanna, Michaels, Skaathun, Morgan, Schneider.
Acquisition, analysis, or interpretation of data: Khanna, Michaels, Skaathun, Green, Young, Schneider.
Drafting of the manuscript: Khanna, Green, Schneider.
Critical revision of the manuscript for important intellectual content: Khanna, Michaels, Skaathun, Morgan, Young, Schneider.
Statistical analysis: Khanna, Schneider.
Obtained funding: Michaels, Schneider.
Administrative, technical, or material support: Michaels, Schneider.
Study supervision: Skaathun, Schneider.
uConnect Study Team: Ishida Robinson, Eve Zurawski, Billy Davis, Ron Stall, Dexter Voisin, Kenneth Mayer, Sam Friedman, Steve Muth, Michelle Taylor, Iman Little, Rebeccah Duvoisin, Ming Chang, Robert Coombs, Elc Estrada, Ben Cornwell, Rachel Behler.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by the National Institutes of Health (grant No. R01 DA 083775).
Role of the Funder/Sponsor: The National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We also acknowledge computing support from University of Chicago’s Research Computing Center, the uConnect Community Advisory Board, and study participants for their time, effort, and dedication. We gratefully acknowledge the contributions of Dexter Voisin, PhD, School of Social Service Administration, University of Chicago, and Kenneth Mayer, MD, Fenway Institute. Dr Voisin received no compensation beyond his established salary for his contributions. Dr Mayer was not compensated for his contributions.
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