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Clinical Context

Preexposure prophylaxis (PrEP) is highly effective in the prevention of HIV infection, but the authors of the current study describe how the uptake of PrEP has been disappointing. In 2015 only 3% of patients eligible for PrEP received a prescription, and this rate improved only to 25% by 2020. PrEP has still been effective in reducing the prevalence of HIV infection, but not all communities have achieved lower rates of HIV. Although White men who have sex with men (MSM) have experienced lower rates of HIV infection in recent years, these rates among Black and Hispanic MSM have increased. Hispanic MSM have the highest increase in the prevalence of HIV infection.

COVID-19 has complicated the prevention of HIV infection. In a study focused on persons of sexual minorities, 1 in 5 people reported increased difficulty in obtaining PrEP prescriptions during the pandemic. This contrasts with the use of treatment for HIV infection, which was demonstrated to remain consistent during the COVID-19 pandemic in 1 study.

The current study evaluates Black and Hispanic men from sexual minority groups to determine whether lack of access to PrEP during the COVID-19 pandemic resulted in a higher number of new HIV infections.

Study Synopsis and Perspective

Changes to HIV PrEP access during the COVID-19 pandemic were linked to higher rates of HIV infection among young sexual minority men and gender-diverse individuals who identified as Black and/or Hispanic/Latino, according to a national survey.

"The public health crisis surrounding COVID-19 had clear impact on PrEP access and risk of HIV acquisition overall," said lead investigator Ethan Morgan, PhD, College of Nursing and the Infectious Disease Institute at The Ohio State University, Columbus.

"This is a stark lesson that when novel public health emergencies arise, extant ones cannot go by the wayside or we risk exacerbating them, such as we see here," he told Medscape Medical News.

The article was published in the October issue of the Journal of Acquired Immune Deficiency Syndromes.

The online survey was administered in 4 waves during the first year and a half of the pandemic, starting in March 2020. Participants were recruited through mailing lists, national networks, community partners, and social media.

Among 796 baseline respondents, 300 agreed to 3 follow-up surveys administered between February and March 2021, between July and August 2021, and between October and November 2021.

Inclusion required participants to identify as Black and/or Hispanic/Latino, be between ages 18 and 29 years, be assigned male at birth, reside in the United States, and have reported anal intercourse with a man in the past 12 months. The researchers noted that given the limited uptake of and adherence to PrEP in the targeted population, they prioritized baseline respondents who reported either current PrEP use or use at least once in their lifetime.

The researchers used separate multivariable logistic regression models to assess the association between odds of testing positive for HIV and other sexually transmitted infections (STIs) across the 4 online study visits and both pandemic-related changes to PrEP access and pandemic-related changes to sexual activity.

Changes in PrEP access were reported by a total of 109 (13.8%) of baseline respondents, and HIV seroconversion was reported in 25 of 292 respondents (8.6%) who reported their HIV and other STI status at follow-up. STI positivity was reported 25.6% of the baseline cohort (n = 204).

Compared with respondents who reported no changes to PrEP access, those who did report change to access were significantly more likely to report HIV seroconversion (adjusted odds ratio [aOR], 2.80; 95% CI, 1.02-7.68). However, Dr Morgan emphasized that the study question did not ask how PrEP had changed, only whether it had.

"While we presume this survey question corresponds to a diminished access to PrEP medication during the COVID-19 pandemic, the question was, 'Has your access to PrEP been impacted by the COVID-19 pandemic?' So, it is unfortunately unclear whether access was diminished or improved," he explained. STI positivity was not associated with PrEP access.

The survey also asked respondents how much the pandemic had affected their sexual activity (measured on a Likert scale of not at all, a little, moderately, quite a bit, and extremely). Respondents reporting greater impact on their sexual activity were more likely to report an STI (aOR, 1.24; 95% CI, 1.10-1.40) during the study period.

In addition, although participants reported a mean of 2.8 sexual partners in the past 3 months, those reporting a greater number were more likely to report an STI (aOR, 1.29; 95% CI, 1.21-1.38).

The researchers suggested that expansion of telehealth and mail-order prescriptions, as well as structural-level interventions addressing pandemic-related unemployment and loss of health insurance, could have helped preserve access to PrEP.

Commenting on the study, Monica Gandhi, MD, MPH, who was not involved in the research, noted that self-reported data can be subject to bias. "However, reduction in services for other medical care has been reported frequently throughout COVID, and so this finding of reduced PrEP access, and subsequent HIV infection, is completely in line with the other studies," she told Medscape Medical News.

Dr Gandhi, who is director of the University of California, San Francisco, Center for AIDS Research and medical director of the HIV/AIDS Clinic ("Ward 86") at San Francisco General Hospital, added: "We knew early on in the COVID-19 pandemic that access to and uptake of PrEP was decreased based on data from Boston's Fenway Institute."

The Boston data, reported July 2020 at the virtual International AIDS Conference, prompted "a real attempt" by clinicians to increase PrEP access and uptake--raising community awareness, dispensing PrEP through mobile units, and changing prescribing patterns--Dr Gandhi said. "We usually see patients every 3 months for PrEP, but with HIV self-testing, we can extend that interval to every 6 months, and we did so in many centers during COVID."

The study was funded by National Institute on Drug Abuse, part of the National Institutes of Health.

Dr Morgan and Dr Gandhi have disclosed no relevant financial relationships.

J Acquir Immune Defic Syndr. Published online October 1, 2022.^[1]

Clinical Implications

• In 2015 only 3% of patients eligible for PrEP received a prescription; this rate improved only to 25% by 2020. Although White MSM have experienced lower rates of HIV infection in recent years, these rates among Black and Hispanic MSM have increased. Hispanic MSM have the highest increase in the prevalence of HIV infection.
• The current study finds that the COVID-19 pandemic resulted in difficulty obtaining PrEP among nearly 14% of sexual minority men of color surveyed, and these challenges were associated with a higher risk for incident HIV infection. Although changes in sexual activity during the pandemic were moderate, altering sexual activity was associated with a lower risk for STI and did not affect incident HIV infection.
• Implications for the healthcare team: With the knowledge that access to appropriate HIV care decreased during the pandemic, the healthcare team should focus on PrEP education and accessibility to as many eligible people as possible.

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