UMD Study Finds Inequity in HIV Prevention

Although pre-exposure prophylaxis, or “PrEP,” medications can dramatically reduce a person’s risk of getting HIV from sex and IV drug use, some groups who could most benefit from taking PrEP are usually not prescribed the drugs, according to a study led by researchers in the University of Maryland School of Public Health.

Published recently in AIDS and Behavior, the research found that PrEP is underprescribed for Black people, heterosexuals, women, those with a recent sexually transmitted infection and those using illicit drugs, said Brad Boekeloo, a professor of behavioral and community health who led the study.

“As a strategy for eliminating HIV infection, it could be highly effective, but the way it is being administered, it is not,” he said.

The study findings reinforce data from the U.S. Centers for Disease Control and Prevention (CDC), which show that PrEP prescriptions are not distributed equitably. While 25% of all those eligible for PrEP were prescribed it in 2020, only 9% of Black/African Americans and 16% of Hispanic/Latino people who would benefit from it had received a prescription.

Boekeloo undertook the study, which examined patient electronic medical records and provider prescription data from the Kaiser Permanente Georgia health maintenance organization (HMO) in Atlanta, to identify patient risk factors associated with HIV infection, and whether these risk factors were mirrored among people who were not HIV-positive and being prescribed PrEP. Risk factors for HIV included being older, Black, male and diagnosed with an STI; having a mental health diagnosis; and reporting same-gender sexual partners.

But CDC-designated risk factors such as exchanging sex for money or drugs, HIV status of sex partners, number of sexual partners and types of sexual behaviors were not available in the Georgia HMO’s electronic medical records—suggesting that these factors could not inform PrEP prescription.

Boekeloo and team, which included lead author Tina Davis MPH ’04, a behavioral scientist with Kaiser Permanente, compared the characteristics of the HIV-positive group (1,049 patients) with those of the non-HIV patients who were being prescribed PrEP (523 patients). They identified which HIV-associated characteristics were associated with a health care provider under- or overprescribing PrEP, interpreting underprescription to members of a high-risk group as inequity.

“While our results may not be surprising, it drives home the point that the health care system is not a bias-free environment,” Boekeloo said. “White men may continue to be privileged in health care. Awareness and equity needs to increase to change this disparity.”