In 2012, Charlotte-Paige Rolle, MD, MPH, and her team at Emory University were in the middle of a study of gay black men, asking why they had such high rates of HIV.

Then, as results started to come in, the US Food and Drug Administration (FDA) approved Truvada® (emtricitabine/tenofovir disoproxil fumarate) for HIV prevention, or preexposure prophylaxis (PrEP).

“We said, ‘This is crazy,'” Dr Rolle told Medscape. “So we scrambled to put together a PrEP willingness questionnaire to give to the [men who have sex with men, or MSM] in the study.”

The result? Black men were just as willing to use PrEP as white men. But when it came to actually getting PrEP, lack of health insurance and lack of primary care physicians were blocking men from getting their hands on the medication.

So when Dr Rolle and her team began planning a new study, they planned a uniquely Southern solution to the PrEP access problem. Without the Medicaid expansion, political will, or finances for widespread PrEP rollout that New York City, San Francisco, and Washington State had , Dr Rolle and her team went small—and in so doing created a new framework for PrEP rollout in low-resource settings in the United States.

“There’s an ethical obligation to ensure that young, black MSM, including those in observational studies, have access to the best possible HIV prevention package, which includes PrEP,” she said. “The South can really benefit from the examples of New York City and San Francisco, and it would be wonderful if we had something similar to what Washington State has, something like an [AIDS Drugs Assistance Program] for PrEP. But you have to have the political will.”

Now, she said, she hopes that the framework she laid out at the Conference on Retroviruses and Opportunistic Infections (CROI) earlier this year will be a guide to others.

Persistent Disparities

Recent data from the Centers for Disease Control and Prevention (CDC) offer some reason to hope. In three different CROI presentations, CDC epidemiologists presented data showing that HIV incidence has dropped by 18% in 6 years.[1,2,3] Another study showed that people with HIV and in care at nine US clinics saw their time with viral loads over 1500 copies/mL drop by 27% in 14 years.[4] What’s more, HIV incidence and percentage of the population still undiagnosed with HIV had dropped or remained stable in every state. Georgia, where Dr Rolle is, saw a 6.1% drop both in incidence and the undiagnosed population every year.

It’s all good news, of course, but it belies persistent disparities: Black people and young people were less likely to benefit from the 18% incidence drop. And while women were more likely to be in care, they were likely to spend the least amount of time with viral loads below 1500 copies.

Existing data show that the same remains true for PrEP. About 79,000 Americans are currently taking PrEP, according to pharmacy data released by Gilead Sciences,[5] which makes Truvada. But who are the people taking it? By and large, they’re white: 74% are white, while 44% of new HIV diagnoses take place among black persons.

Author: Heather Boerner