Pre-exposure prophylaxis (PrEP) is a medication that substantially prevents HIV acquisition. One form of PrEP involves a single pill containing tenofovir disoproxil fumarate and emtricitabine taken daily. Recently, an injectable form of cabotegravir was FDA-approved for use every two months. There are massive disparities in PrEP initiation and adherence by income, race, ethnicity, age, gender, and region. For example, Black sexual minority men in the South are among some of the lowest users of PrEP in the country. Disparities in PrEP uptake are caused in part by inequities in access to care for racial and sexual minority groups. Therefore, last year I worked with several colleagues to introduce a novel proposal for a national PrEP access program to decrease disparities in access. I have also had the privilege of meeting with some federal officials who are working to expand PrEP access through innovative financing and delivery models. However, I am not sure if increased PrEP access will be enough to reduce disparities.
I conducted an autoethnography published in the Journal of Environmental Research and Public Health that documented my journey as a PrEP-using peer change agent in an NIH-sponsored intervention I led to improve perceived HIV risk and PrEP initiation among Black gay men. In the article, I describe how although access was never a concern, navigating other socioecological factors such as medical mistrust, stigma from self, clinical care teams, and partners, and reconciling multiple marginalized identities was more salient, difficult, and influential in adherence. PrEP was a constant reminder of being a part of a highly marginalized group and exacerbated feelings of loneliness and vulnerability. PrEP adherence triggered unresolved emotional and psychological factors as a minority American that are inadequately addressed by PrEP care or research teams. There was no mechanism in place to help support adherence given the fact that as an individual who is absent of disease, I did not really have to take that medicine and constantly be triggered by “the system.”
We certainly need to increase access to PrEP and reduce socioeconomic barriers for those who want to use it. However, we cannot end our work to reduce disparities at increasing access. As we consider innovative delivery and care models, we should also consider how we could alleviate other socioecological barriers in the PrEP care experience for minority communities. This is crucial because psychosocial factors can reduce medication adherence in the presence of increased access to care, particularly for highly marginalized groups such as Black sexual minority men. We should consider how clinical care teams could be better sources of support during and in-between visits. My work also suggests that clinicians should use PrEP to alleviate sexuality- and medication-based stigma and reduce medical mistrust.
I am not sure how these issues will manifest for the injectable version of PrEP. Honestly, given my research, I believe the issues and barriers will be similar. Still, I have hope that with more attention being given to improving access to care, we will continue moving in the right direction towards truly promoting overall health and reducing disparities.