Advancing PrEP in the Southern United States

Man holding a pill.
Man holding a pill.
To improve steps along the PrEP care continuum for HIV prevention, sustainable program strategies are vital in the black and Latino MSM populations in the southern United States.

To improve steps along the pre-exposure prophylaxis (PrEP) care continuum for HIV prevention, sustainable program strategies are vital in the black and Latino men who have sex with men (MSM) populations in the southern United States, according to study results published in AIDS Patient Care and STDs.

Although PrEP is a promising strategy for HIV prevention, awareness and coverage remain low especially in populations with an elevated risk for transmission. Both black and Latino MSM are priority populations with low PrEP coverage but elevated HIV incidence, with only 1% of black and 3% of Latino individuals with PrEP indications prescribed such medication in 2015. In addition, the southern United States also remains a critical target for increasing PrEP uptake since this region has the highest percentage of people of minority race/ethnicity with a PrEP indication and the lowest number of PrEP prescriptions relative to new HIV diagnoses. Serving predominantly uninsured populations, public health centers and federally qualified health centers may be uniquely positioned to improve PrEP access. Therefore, this retrospective study evaluated the PrEP continuum in this collaborative model between a public health department and a federally qualified health center in North Carolina and compared characteristics of patients who ultimately initiated PrEP with patients who did not.

The steps along the PrEP continuum, initiation, retention, and adherence components and an initial stage specific to the unique referral process, were analyzed. Profiling the continuum allowed the determination of gaps that patients may fall through. Based on these gaps, efforts should be aimed at encouraging same-day PrEP initiation visits, and advocating for increased funding for PrEP initiation services to be provided directly from the sexually transmitted infections (STI) clinic.

A total of 196 patients were referred from the STI clinic to the federally qualified health center for PrEP care. Of these patients, 60% attended an initial appointment, 43% filled a prescription, 38% persisted in care for >3 months, and 30% reported >90% adherence at follow-up. In total, 117patients presented for their initial appointment; 81% were MSM, 53% were black, 18% were Latino, 8% were transgender, and 47% were uninsured. When comparing PrEP initiators to non-initiators, there were statistically significant differences based on race and ethnicity (black participants were more likely to be non-initiators: 73% vs 45%; P =.02), history of sex work was also associated with non-initiation (12% vs 2%; P =.05), and insurance status (patients without insurance were more commonly non-initiators [64% vs 40%; P =.05]).

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This program also determined the reasons some referred patients did not make their PrEP appointments at the federally qualified health center. In total, 28 patients missed their visits, 8 of whom were successfully contacted via telephone questionnaire and provided reasons for missing their visit. Reasons for not making the initial PrEP appointment included preference for PrEP through their primary care providers, cost of medications, forgetting or difficulty getting to appointments (eg, because of work conflicts or no transportation), personal issues, and unsure interest in PrEP. Having a clearer understanding of why patients fall out of the continuum of pre-exposure antiretroviral care is critical to improve and guide interventions that are adapted to this population.

Overall, the study authors concluded that, “Our referral model was able to reach priority populations including persons of color and the uninsured in our community, but additional efforts (such as PrEP navigation, case management, and data sharing) are vital to increasing the proportion of individuals engaged along the PrEP care continuum.”


Clement ME, Johnston BE, Eagle C, et al. Advancing the HIV pre-exposure prophylaxis continuum: a collaboration between a public health department and a federally qualified health center in the southern United States [published online June 24, 2019]. AIDS Patient Care and STDs. doi:10.1089/apc.2019.0054