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AIDS 2016: San Francisco and New York Lead in PrEP Use

, by Liz Highleyman

BETA is reporting from the 21st International AIDS Conference this week in Durban, South Africa—bringing you the latest news, updates, and research on HIV treatment and prevention.

More than 79,000 people in the U.S. have started Truvada for HIV pre-exposure prophylaxis (PrEP) over the past four years, researchers reported at the 21st International AIDS Conference (AIDS 2016) taking place this week in Durban, South Africa.

The biggest gains have been seen in cities like San Francisco where gay men and community groups have promoted its use. But other groups are not benefitting as much as they could, and PrEP use lags behind in the south, which has a high rate of new HIV infections.

The U.S. Food and Drug Administration approved Truvada (tenofovir/emtricitabine) for HIV prevention in July 2012. PrEP use began rising in late 2013, but it has been difficult to estimate the total number of people who have used it because this information is not centrally collected.

Scott McCallister

Scott McCallister (Photo: Liz Highleyman)

Scott McCallister, MD, and colleagues at Gilead Sciences conducted an ongoing survey of Truvada prescriptions for PrEP at retail pharmacies in the U.S., collecting de-identified patient data from medical records. They first presented their findings at a conference in 2013, reporting that fewer than 1,300 Truvada PrEP prescriptions were filled in 2012 at the 55% of pharmacies that responded, with about half of them being for women.

At AIDS 2016 McCallister reported the latest cumulative (added up over time) numbers for Truvada PrEP prescriptions dispensed at 80% of U.S. retail pharmacies between January 2012 and December 2015.

The Truvada combination pill is also used for HIV treatment, post-exposure prophylaxis (PEP), and off-label hepatitis B treatment, so the survey omitted people with these conditions indicated in their pharmacy records (for example, those taking more than one antiretroviral drug).

The survey found that a total of 79,684 unique individuals—that is, not counted more than once if they filled multiple prescriptions—started Truvada for PrEP by the end of 2015. The numbers rose from just 1,671 prescriptions in late 2012 to 14,000 in late 2015—an increase of 738%.

Among these PrEP users, 60,872 were men and 18,812 were women. Although women made up almost half of those who started PrEP in 2012, the proportion fell to about a quarter in 2015. While the absolute number of women taking PrEP rose slightly over time, the much larger increase among men lowered women’s share of the total.

The average age of people starting PrEP was 36 years, but the women were a bit younger than the men (33 vs 37 years, respectively). While 28% of women taking PrEP were under age 25, this was the case for only 11% of the men.

McCallister said it was harder to analyze the race or ethnicity of PrEP users because this information is generally not included in pharmacy prescription records. But he did say that those with available data were disproportionately white. At the recent ASM Microbe meeting the research team reported that among the 44% of PrEP users with available racial/ethnic data, 74% were white, with Hispanics (12%), African-Americans (10%), and Asians (4%) accounting for much smaller proportions.

Numbers Too Low

Experts agree that the numbers McCallister reported are too low, though it is not clear how low.

Many public and private clinics—including San Francisco City Clinic and the San Francisco AIDS Foundation sexual health center at Strut—send their clients to retail pharmacies to get their Truvada PrEP prescriptions filled. But Gilead’s pharmacy survey does not include people who received PrEP through clinical trials or demonstration projects, the Medicaid system, or medical systems that do not report their numbers (such as Kaiser Permanente).

A geographical breakdown of the numbers reported by McCallister shows that five states—California, New York, Texas, Florida, and Illinois—accounted for just over half of all Truvada PrEP prescriptions nationwide. Along with their large size, some of these states are home to cities with big gay populations that have promoted PrEP within their communities.

Looking only at 2015, the pharmacy survey found that PrEP was prescribed to 2,936 people in New York City; 1,094 in San Francisco; and 1,001 in Chicago. These were followed by 840 in Washington, D.C., 660 in Los Angeles, 574 in Seattle, 548 in Boston, 524 in Atlanta, and 500 in Philadelphia. While these numbers are too low, they probably give a good sense of the ranking of the various cities.

A recent informal survey of large PrEP providers in San Francisco put the cumulative number of users at more than 6,000, including 1,000 at Strut and 1,800 at Kaiser Permanente San Francisco. These figures are not strictly comparable—they reflect total prescriptions over time, not just for a single year— but they give an idea of the shortfall in the reported numbers. 

McCallister noted that the numbers in the pharmacy survey do not reflect the distribution of the HIV epidemic in the U.S. According to the Centers for Disease Control and Prevention, 44% of new HIV diagnoses occur among African-Americans, who make up about 12% of the U.S. population. Young black gay and bisexual men are at especially high risk, and the highest rates of new infections are mostly seen in states in the southeast.

Asked at an AIDS 2016 press conference about reasons for the disparities in PrEP use in different groups, McCallister suggested that gay men and perhaps transgender people may have a greater comfort level using PrEP because their providers are more knowledgeable about it and their communities have done more peer-to-peer education.

Women, on the other hand, may have fewer “touch-points” for accessing PrEP, as the reproductive health clinics and OB/GYNs they attend may not be as informed as sexual health clinics serving gay men, highlighting the need for broader education and awareness efforts.

Liz Highleyman is a freelance medical writer and editor-in-chief of HIVandHepatitis.com.

Want more news and research from the AIDS 2016 Conference? Click here to find more on BETA.

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