Growing racial and gender PrEP inequities in England, despite increased access

The proportion of Black African women diagnosed with HIV increased between 2017 and 2021 in England, while the proportion of new diagnoses among White men dropped by 20%. Over this period, the proportion of PrEP users who were women, including Black African women, fell. Thus, when comparing Black African women to White men, and women to men, PrEP inequities have increased substantially, despite wider PrEP accessibility.

Background

The annual number of new HIV diagnoses have fallen substantially in the UK over the past two decades, from a high of around 8,000 in 2005 to a low of 2,955 in 2021 – a 64% reduction.

In England, this trend has been particularly marked among gay and bisexual men. However, the decline has not been as steep for other populations, such as Black women, people of Asian ethnicity, injecting drug users, and people living outside London.

Despite PrEP’s high effectiveness at preventing HIV transmission, the first time it was provided by the National Health Service (NHS) in England was through the Impact Trial from 2017 to 2020, with only 26,000 places available. Recruitment was heavily skewed to gay and bisexual men, although they accounted for less than 40% of new diagnoses in 2020. Factors such as varying levels of PrEP knowledge, self-perception of HIV risk, and access to a PrEP provider in different population groups, along with HIV stigma, have been identified as the main reasons for this PrEP inequity.

From October 2020, PrEP has been freely available through NHS sexual health services in England (as it had been in Scotland and Wales since 2017). However, it has been unclear if this availability has helped to bridge the uptake gap for some key population groups, such as Black women.

The study

Researchers compared numbers of people receiving one or more PrEP prescriptions in two distinct periods: that of the PrEP Impact Trial period (October 2017 to February 2020) and the full 2021 calendar year. Lockdowns during 2020 meant that there was a reduction in all sexual health services, including PrEP, so this period was omitted from the analysis. For 2021 clinic attendees, information such as PrEP uptake and continuance, PrEP regimen (daily or event-based dosing), the number of tablets prescribed and basic demographic data was available.

Additionally, researchers considered national HIV diagnoses for these two periods, reported from sexual health and HIV clinics, laboratories, and community settings. As they were mainly concerned with HIV diagnoses that could have been prevented by PrEP, they excluded late diagnoses (identified by the presence of an AIDS-defining illness, a CD4 count below 350 cells within 91 days of diagnosis, and no evidence of recent seroconversion). Anyone diagnosed in England who had already been diagnosed abroad was also excluded.

To report inequities, researchers used the PrEP-to-need ratio (PnR): the number of PrEP users divided by the number of new HIV diagnoses within a given period. This can be calculated for all people diagnosed with HIV, and for specific subgroups, such as Black women diagnosed with HIV. A PnR below one indicates insufficient PrEP coverage for the number of new diagnoses for that group. While higher PnRs would indicate better PrEP coverage, a very high PnR in one group but not another is indicative of inequitable coverage.

PrEP inequities

A total of 21,292 participants were recruited during the PrEP Impact trial, with 5,019 new HIV diagnoses (excluding late diagnoses) during this period in England; this resulted in an overall PnR of 4.2. In 2021, there were nearly three times as many PrEP users (60,384) and a fourfold decrease in new HIV diagnoses (1,234), resulting in a PnR of 48.9 – eleven times more than the during the trial period.

Almost all the PrEP Impact Trial participants were gay and bisexual men, at 99%. This decreased to 82% of PrEP users in 2021. However, this was mainly driven by more heterosexual men starting PrEP by 2021, an increase from just over 1% to around 13% of all PrEP users.

Women accounted for a smaller proportion of PrEP users by 2021, decreasing from 2.9% to 2.0%. However, they accounted for a greater proportion of new HIV diagnoses, from 1,219 (24%) to 338 in 2021 (27%). This meant that men went from a PnR of 5.4 during the Impact Trial to a PnR of 63.9 in 2021, while women went from a PnR of 0.5 to 3.5. This translated into the equity gap widening by nearly 70% between men and women. This finding was consistent across age groups, ethnicities, and regions of residence.

Transgender people saw a large increase in PnR between periods: from 50.7 during the trial to 131.6 in 2021.

Looking at race/ethnicity, White men had the highest PnR for both periods – this increased dramatically from 7.1 to 96 in 2021. Black African women had the lowest PnR, which increased very minimally from 0.1 to 0.3. While the proportion of new HIV diagnoses increased for Black African women (8% to 10%), it decreased for White men (44% to 35%).

Contrary to what researchers expected to see with more accessible PrEP, the equity gap for these two groups increased between the periods, and substantially. During the PrEP Impact Trial, the difference was 78-fold; in 2021, it increased to 278-fold. This represents a 3.5 times higher equity gap between periods for White men compared to Black African women.

In both time periods, the lowest PnR was for Black African people, with people in the Black Other group and Black Caribbean people consistently in the second and third lowest positions.

The race/ethnicity divide was consistent across regions of residence. Also in terms of regional trends, while men from London comprised one-third of new HIV diagnoses and just over half of all PrEP users (52%) during the trial, they only made up a quarter of new diagnoses and 55% of all PrEP users in 2021. This represented a 16-fold increase between these periods. This was the highest PnR increase across residence regions and gender groupings. Residents in the Midlands and East of England had the lowest PnRs across time periods, and the lowest PnR increase. Thus, the equity gap between men in London and these regions was around two to three times higher, respectively.

Conclusion

“PrEP delivery should be guided based on equity metrics (PrEP use relative to HIV epidemic), not PrEP equality (equal across groups, regardless of the proportion of HIV diagnoses),” the authors say. “On this basis, the PrEP Impact trial and subsequent PrEP commissioned service demonstrate large and widening equity gaps by gender, ethnicity, and geography, especially those of older age, women of Black ethnicity and those outside of London… To reach the UK Government’s aim to stop HIV transmissions by 2030, it will be key to address the barriers to PrEP access and other HIV preventions faced by these underserved populations.”