Study Shows Disparities in HIV PrEP

A new study conducted by UCLA researchers Nina T. Harawa, Diane Tan, and Arleen A. Leibowitz, examined disparities in uptake of HIV pre-exposure prophylaxis (PrEP), using a cohort of California Medicaid enrollees. The findings were published in the March issue of Health Affairs.

Harawa

“My coauthors and the Southern California HIV Policy Research Center have been doing research around PrEP for some time,” explains Harawa, which led her to wanting to explore both the policies and the more individual and couple/family-level factors that might impact uptake.

Past studies have identified substantial disparities in PrEP use, but few of those have done so in a group where everyone is able to access PrEP without prior authorization or other financial costs to the patient.

“PrEP is available to Medicaid beneficiaries in California, and Medi-Cal (California’s Medicaid program) covers one in five California adults,” Harawa says. “So, this was an ideal and a very large population in which to examine differences in uptake. Our goal was to measure these and then to determine if disparities by race and Hispanic origin could be explained by differences in the risk profiles or age distributions of the population.”

The researchers examined data from 2019 that had information on nearly 6 million Medicaid beneficiaries, ages 16-69. The data included classification by race. They found that uptake was highest for White and Black males and lowest for Hispanic males. Meanwhile, Black females had the highest uptake and twice the rate of PrEP uptake of White females.

“Rates for males far exceeded those for females,” says Harawa. “After taking into account age-differences between groups and a measure of need for PrEP, however, large disparities emerged, with White male beneficiaries having much better PrEP coverage than Black male and female or Hispanic male beneficiaries.”

Interestingly, beneficiaries, ages 16-24, had lower rates of PrEP uptake than those 25-34 or 35-69 even though this young group has a relatively high level of HIV risk.

Harawa and her colleagues did not use data on sexual or substance-use related behaviors among the Medicaid beneficiaries, but they made use of an external sample to assess whether differences in risk behaviors account for differences in PrEP uptake.

“Our findings did not support this,” Harawa says. “After controlling for this measure of risk, which includes behaviors like number of sex partners and injection drug use among others, disparities by race and Hispanic origin did not change.”

It was obvious from the researchers’ conclusion that disparities in use of highly effective prevention strategies such as PrEP continue to exist, even among people enrolled in Medi-Cal, which makes PrEP available free and without prior authorization.

“It is also important to note that overall rates in this population were low,” Harawa says. “Focused outreach, education, and technical support to Medicaid agencies and Medicaid managed care organizations to increase PrEP use, as well as to expand Medicaid under the Affordable Care Act should be prioritized.”