PrEP Enrollment: Where Are the Young Black Guys?
Out of all gay and bisexual men in the U.S., the highest percent of new HIV infections occur in African American men. Yet the number of African American men accessing pre-exposure prophylaxis (PrEP) to prevent HIV may be lower than men of other demographics. Only seven percent of participants part of a PrEP demonstration project conducted in three major U.S. cities between 2012 and 2013 were black, and one study found that heightened concerns over potential side effects may pose one significant barrier to PrEP uptake among African American men. PrEP won’t be nearly as effective as proponents hope if those in high-risk groups don’t know about it, aren’t talking about it, or are scared to take it. That’s one outcome that Hyman Scott, MD, is trying to avoid.
Dr. Scott is a provider for the 360: Positive Care Center at the University of California, San Francisco. As part of this position, he discusses and prescribes PrEP to patients—mostly to men, although the clinic will prescribe PrEP to appropriate candidates of any gender.
“As more and more people learn about PrEP, inquire about it, and seek it out, one of the things we want to do is make sure that it also reaches the communities of color in San Francisco—particularly among young men of color who have sex with men,” Dr. Scott notes.
How PrEP is perceived—its acceptability—will influence how quickly or widely it will be used. And negative perceptions of PrEP—whether or not they’re true—can stymie public health efforts to promote PrEP uptake. Dr. Scott has already observed that conversations around PrEP aren’t happening in the same way in every community. He believes that young African American men are talking about PrEP less frequently than their white counterparts.
Blue Williams, clinical therapist for the DREAAM Project at San Francisco AIDS Foundation, sees evidence of this among the young gay, bi, and transgender African American men he meets. At this point, Williams notes that, “it’s real to them and not real to them at the same time. I think without a lot of exposure to PrEP, it’s like a magic bean or something. It’s more just whispers and rumors.”
Both Dr. Scott and Williams believe that word-of-mouth will play a pivotal role in encouraging PrEP use in this population. “It’s the same as if you hear a critic talk about a restaurant. I’ll read or listen to the review, but I’m also going to ask someone I know if they’ve eaten there—and that will have more of an impact on me. In this community, word of mouth is huge, and it tends to guide a lot,” explains Williams.
People who ultimately access PrEP are oftentimes those who’ve discussed it with friends, partners, or others with personal experience taking it. Those conversations help shape norms about PrEP and can establish it as something that people think of as beneficial or acceptable. If African American men aren’t hearing or talking about PrEP, they’re at a distinct disadvantage because they might not be finding out about how it could benefit them.
Dr. Scott thinks, first and foremost, this muted conversation may be a continuation of disparities experienced by African American men in other forms of health care. Structural barriers—like poverty, incarceration, or unstable housing—that may be encountered more often by African Americans—can have a big effect on if and how people access the health care services they need.
“We see this in other aspects of HIV care and with other medical advancements. People who are marginalized in some way aren’t the first to find out about or access these new sorts of advancements. And PrEP is new,” he explains.
Stigma may also play a role in how willing young African American men may be to either talk about—or take—an HIV medication to prevent infection. “Stigma around HIV is still a challenge in the African American community. And Truvada is an HIV medication,” notes Dr. Scott. Young men may be hesitant to take PrEP if they worry what friends or other community members will think if they see an HIV medication being taken, he explains.
And the impact of stigma extends beyond how others might treat them if they are perceived to be taking PrEP. As Dr. Scott explains it, there’s also a connection between stigma that young black men experience—because of their race or sexual orientation—and how comfortable they’ll be having discussions about sex or talking to providers about PrEP.
Young African American men may also have to overcome stigma related to accessing health care services on a regular basis. Williams has noticed a perception held among his group members, who might not have insurance and only access health care in emergency situations, that there’s something abnormal about accessing preventive care. “There’s this perception, that, ‘there’s something wrong with you.’ You’re tainted, and we don’t want to be anywhere near you.’”
Williams also thinks that fear may play into PrEP decisions. Beginning PrEP means that men consciously acknowledge the risk they have of acquiring HIV. He says that, for some men, “it’s easier to have sex without a condom and not think about the consequences.” Once you bring PrEP into the discussion, men have to actually think about their risk and what their sexual health decisions mean.
So what can be done?
Encouraging community members to talk about PrEP is key. So is quashing rumors or misconceptions that people may have, according to Williams. He helps facilitate conversations between men who are taking PrEP and men who are interested or just need more information. “These kinds of conversations help PrEP become something that’s more of an option in someone’s mind. Putting a real face to something always helps,” he notes.
Dr. Scott points to the role that providers can play. He notes that initiating the conversation—and being comfortable bringing up this topic with patients—is a vital first step.
“Providers have the ability to move this discussion about PrEP to the forefront. If a patient doesn’t feel comfortable bringing up the question of PrEP on their own, the provider should feel confident asking about sex and letting men know what their options are. We also have to make sure that providers have the information they need so that they feel comfortable prescribing PrEP.”
To reach young African American men in a meaningful way, Williams says providers have to “give a bit more of themselves” to make the idea of PrEP be something that’s seen as relatable, realistic, and attainable. “A lot of these men, they’re vulnerable. They’ve been used, abused, and neglected. They’re reticent to do anything if they don’t have trust—and for providers to be trusted they have to give a little of themselves, because that’s what makes it real. So providers should talk about if they’re on PrEP, if their partner is on PrEP, or if they know what other people experience on PrEP.”
For HIV specialists, Dr. Scott raises the possibility of reaching people who need PrEP through their partners. People living with HIV drastically reduce the risk that they’ll transmit HIV to a partner if they’re able to reach undetectable viral load levels. Dr. Scott presents PrEP as an option for the partners of his HIV-positive patients even when his patient has is undetectable— especially if there are other partners.
Dr. Scott has initiated events to educate and build awareness about PrEP. At a recent Black Brothers Esteem event at San Francisco AIDS Foundation, he fielded questions about PrEP and PEP. He notes that oftentimes, the questions he gets from men center around if Truvada is safe and if it’s effective. Because, he notes, there’s still some fear in the African American community about HIV medication toxicity, it’s important to address those concerns head-on. And with good efficacy and safety data available about Truvada, Dr. Scott is confident in backing PrEP as an effective and safe prevention strategy.
In his conversations with patients or others, he always stresses the “package” that PrEP is part of—because, as he explains it, “PrEP isn’t just taking a pill. We want you to come in every three months to have an evaluation and to have other STI checks. We want to be able to speak with you about your partners, your HIV status, and disclosure and testing. We want to encourage you to use condoms, and provide skills on condom negotiation. It’s an opportunity to talk to men about their sexual health in a larger context.”
Seen in this light, PrEP is an opportunity to link and engage young African American men with health care. “A lot of men don’t see providers unless something is going wrong. PrEP can be a great tool to help men connect with primary care in the same way that contraception is a link for some women to stay engaged with care.”
Wondering whether PrEP might be right for you? Have burning questions about this new HIV prevention tool? Or are you a provider who is looking for more information about prescribing PrEP? Find answers in our “virtual library” on PrEP, with a myth-busting video, personal stories, provider perspectives, and more.