Young gay men of color find PrEP acceptable, but struggle with adherence
Young gay men of color are a group at highest risk for HIV in the U.S. If current trends continue, half of Black and a quarter of Latino men who have sex with men will be diagnosed with HIV during their lifetime, according to the Centers for Disease Control. PrEP, a highly effective biomedical HIV prevention strategy, may benefit young gay men of color—but only if it’s accessibly, acceptable, and taken up and used.
“Sexual health can be so secretive,” said Terrance Wilder, who coordinates DREAAM, a program for young gay men of color at San Francisco AIDS Foundation. “And that will always be a barrier for PrEP unless we break through. People may not want to talk about their HIV status. Or the fact that they had sex last night. They gave oral sex but they’re ashamed to say that they sucked a penis. If we can talk about sprained ankles—we should be able to talk about HIV, gonorrhea and chlamydia.”
A recent study, published this month in JAIDS by Sybil Hosek, PhD and colleagues, gives insight into the challenges of PrEP uptake by young gay men of color. The study (ATN 110), was a phase II safety study of PrEP use among young men who have sex with men between the ages of 18 and 22 in 12 urban U.S. cities.
Two hundred young people were enrolled into the study. Two-thirds (66%) were Black or African American, and over a quarter (26%) were Latino. Participants qualified for the study if they reported high-risk sexual behavior that would increase their risk for HIV. Over a quarter (29%) reported exchanging sex for money; over 80% reported condomless anal sex in the previous month; over half (58%) reported condomless receptive anal sex with their last partner.
This is the “youngest and most diverse cohort of YMSM [young men who have sex with men] of any domestic PrEP study to date,” said Hosek and colleagues.
Most (71%) of the young people who enrolled completed the entire 48 weeks of the study, and most participants tolerated—even liked—the PrEP services they received (which included counseling as well as regular HIV and STI testing). About 60% of the young people who participated said that taking a PrEP pill every day was acceptable.
More than half of the participants had tenofovir levels consistent with four or more doses/week at the beginning of the study—but this declined over time. A “noticeable drop-of occurred at week 24,” the authors said. By week 48, only 34% of participants had this level of drug detected in their blood samples.
Black and African American participants had, on average, worse adherence compared with the rest of the study participants. At every time point, the median level of drug detected in blood samples was below the protective four pills/week threshold.
Study participants reported missing doses for a variety of reasons. The most common reasons were that they “simply forgot,” were “away from home”, or were “too busy with other things.”
Tony Bradford, program manager of DREAAM, said this is a common question among the young men he supports in DREAAM. This month, his team held a PrEP education event where DREAAM participants had a chance to learn about PrEP, ask questions about its use, and get more information on where to access it.
“We hear the kinds of questions that people ask when they first start taking a medication,” said Bradford. “Like, ‘What are the side effects?,’ and, ‘Can you miss doses?’ But the other thing we hear is, well, ‘My life is chaotic. I can’t even take aspirin every day! Is there some way someone can help me with this?’”
Hosek and colleagues’ study reinforces the importance of adherence counseling for young men who have sex with men beginning PrEP. Adherence “boosters,” such as reminder text messages or check-in calls may be helpful, as might more frequent PrEP clinic visits, the authors said.
“The population we work with, they’re very guarded,” said Wilder. “A lot of people on the street have been hurt, have been betrayed, have been used. We have to do things from the heart—to connect with participants and make sure they have a space where they can communicate and learn. With PrEP, I want them to be comfortable speaking about it. Even if they’re not on it—I just want them to be educated about it. We just want to give people the friendly option of it.”
Hosek, S. G. and colleagues. An HIV Preexposure Prophylaxis Demonstration Project and Safety Study for Young MSM. JAIDS, 74. 2017.