Addressing Barriers to PrEP Uptake Among Black MSM

Key Takeaways:

• Racial disparities exist in access to and uptake of pre-exposure prophylaxis (PrEP) in the United States, particularly among Black men who have sex with men (MSM).
• Daily dosing of PrEP may be a barrier to PrEP uptake and adherence in some Black MSM.
• For MSM, on-demand dosing of oral emtricitabine/tenofovir disoproxil fumarate and injectable cabotegravir can be considered.

Racial Inequities in PrEP Access
There are major inequities in access to and uptake of HIV pre-exposure prophylaxis (PrEP) within communities of color, especially among Black men who have sex with men (MSM). I think my PrEP patient population reflects the population seen by many other healthcare professionals, which is predominantly White men who are gay or bisexual, and, unfortunately, the few Black MSM whom I do provide services for often have low persistence in care. One of the best ways we can encourage PrEP uptake and persistence among Black MSM is through offering and educating them about nondaily PrEP regimens to allow for more autonomy in their decisions around adherence. Below I discuss several nondaily PrEP regimens that I believe can help overcome barriers to PrEP uptake and persistence in Black MSM.

On-Demand Oral Emtricitabine/Tenofovir Disoproxil Fumarate (2:1:1)
In my practice, I sometimes see MSM who do not want to take PrEP daily because they have sex infrequently or intermittently. When MSM are confident in predicting when they will have sex, I consider off-label use of on-demand PrEP as a viable option based on the International Antiviral Society–USA and WHO guideline recommendations.

When discussing on-demand emtricitabine/tenofovir disoproxil fumarate as an option with MSM, I typically show them a pictogram of the dosing regimen to make it easier to digest: 2 pills between 2 and 24 hours before a sex act, 1 pill 24 hours after the initial pills, and 1 pill 48 hours after the initial pills. The pictograms help them determine if it is something they think they can and want to do. I have had a handful of patients who have really flourished with this regimen.

As a healthcare professional, it is important to note that on-demand PrEP is not recommended for use in heterosexual men. This regimen also should not be used for MSM with hepatitis B virus infection or MSM likely to have difficulty adhering to a complex dosing regimen (eg, adolescents or patients with active substance use disorders).

Injectable Cabotegravir
Cabotegravir is a long-acting injectable given every 8 weeks and is another great option for Black MSM who do not want a daily regimen. I have been educating all my patients about this option, and although some say that needles are not for them, others get very excited. This is something that has been asked for by our patients having problems adhering to daily regimens and others who would prefer not to take a daily regimen. I think that the freedom of not taking a pill every day—not having to set an alarm on their phone, not having a key chain pill dispenser—is liberating for our patients.

There have been some barriers to patient access to cabotegravir at many clinics, especially in states like mine that have no expanded Medicaid. However, clinics typically initially struggle with implementation for any new modalities, or even new oral therapies, so I am optimistic that our clinics will find solutions with the help of patient advocates.

Closing the Gap
The more PrEP options we have available for our patients to individualize their care, the more likely they are to feel empowered to take control of their PrEP care. This alone will not remedy inequities affecting PrEP uptake and persistence but may provide some avenues for change if partnered with removal of key structural barriers.

Your Thoughts?
What are you doing in your practice to close the PrEP uptake and usage gap among Black MSM? Join the discussion by posting in the comments section.