Changes in HIV Preexposure Prophylaxis Awareness and Use Among Men Who Have Sex with Men — 20 Urban Areas, 2014 and 2017

In February 2019, the U.S. Department of Health and Human Services proposed a strategic initiative to end the human immunodeficiency (HIV) epidemic in the United States by reducing new HIV infections by 90% during 2020-2030* (1). Phase 1 of the Ending the HIV Epidemic initiative focuses on Washington, DC; San Juan, Puerto Rico; and 48 counties where the majority of new diagnoses of HIV infection in 2016 and 2017 were concentrated and on seven states with a disproportionate occurrence of HIV in rural areas relative to other states.† One of the four pillars in the initiative is protecting persons at risk for HIV infection using proven, comprehensive prevention approaches and treatments, such as HIV preexposure prophylaxis (PrEP), which is the use of antiretroviral medications that have proven effective at preventing infection among persons at risk for acquiring HIV. In 2014, CDC released clinical PrEP guidelines to health care providers (2) and intensified efforts to raise awareness and increase the use of PrEP among persons at risk for infection, including gay, bisexual, and other men who have sex with men (MSM), a group that accounted for an estimated 68% of new HIV infections in 2016 (3). Data from CDC's National HIV Behavioral Surveillance (NHBS) were collected in 20 U.S. urban areas in 2014 and 2017, covering 26 of the geographic areas included in Phase I of the Ending the HIV Epidemic initiative, and were compared to assess changes in PrEP awareness and use among MSM. From 2014 to 2017, PrEP awareness increased by 50% overall, with >80% of MSM in 17 of the 20 urban areas reporting PrEP awareness in 2017. Among MSM with likely indications for PrEP (e.g., sexual risk behaviors or recent bacterial sexually transmitted infection [STI]), use of PrEP increased by approximately 500% from 6% to 35%, with significant increases observed in all urban areas and in almost all demographic subgroups. Despite this progress, PrEP use among MSM, especially among black and Hispanic MSM, remains low. Continued efforts to improve coverage are needed to reach the goal of 90% reduction in HIV incidence by 2030. In addition to developing new ways of connecting black and Hispanic MSM to health care providers through demonstration projects, CDC has developed resources and tools such as the Prescribe HIV Prevention program to enable health care providers to integrate PrEP into their clinical care.§ By routinely testing their patients for HIV, assessing HIV-negative patients for risk behaviors, and prescribing PrEP as needed, health care providers can play a critical role in this effort.

In February 2019, the U.S. Department of Health and Human Services proposed a strategic initiative to end the human immunodeficiency (HIV) epidemic in the United States by reducing new HIV infections by 90% during 2020-2030* (1). Phase 1 of the Ending the HIV Epidemic initiative focuses on Washington, DC; San Juan, Puerto Rico; and 48 counties where the majority of new diagnoses of HIV infection in 2016 and 2017 were concentrated and on seven states with a disproportionate occurrence of HIV in rural areas relative to other states. † One of the four pillars in the initiative is protecting persons at risk for HIV infection using proven, comprehensive prevention approaches and treatments, such as HIV preexposure prophylaxis (PrEP), which is the use of antiretroviral medications that have proven effective at preventing infection among persons at risk for acquiring HIV. In 2014, CDC released clinical PrEP guidelines to health care providers (2) and intensified efforts to raise awareness and increase the use of PrEP among persons at risk for infection, including gay, bisexual, and other men who have sex with men (MSM), a group that accounted for an estimated 68% of new HIV infections in 2016 (3). Data from CDC's National HIV Behavioral Surveillance (NHBS) were collected in 20 U.S. urban areas in 2014 and 2017, covering 26 of the geographic areas included in Phase I of the Ending the HIV Epidemic initiative, and were compared to assess changes in PrEP awareness and use among MSM. From 2014 to 2017, PrEP awareness increased by 50% overall, with >80% of MSM in 17 of the 20 urban areas reporting PrEP awareness in 2017. Among MSM with likely indications for PrEP (e.g., sexual risk behaviors or recent bacterial sexually transmitted infection [STI]), use of PrEP at recruitment events using venue-based sampling ¶ (4). Eligible participants** completed a standardized questionnaire administered in person by trained interviewers. All participants were offered anonymous HIV testing and incentives for the interview and HIV test. † † Analysis was limited to eligible participants at risk for HIV infection who were likely to meet clinical indications for PrEP § § (2). Specifically, the analysis was limited to MSM who had a negative NHBS HIV test result, did not report a previous ¶ The number of U.S. urban areas collecting data differed in 2014 and 2017.
The HIV-positive test result, had either one male sex partner who was HIV-positive or two or more male sex partners in the past 12 months, and reported either condomless anal sex or a bacterial STI (i.e., syphilis, gonorrhea, or chlamydia) in the past 12 months. PrEP awareness and use were measured differently in 2014 and in 2017. In 2014, participants were asked whether they had "ever heard of people who do not have HIV taking anti-HIV medicines, to keep from getting HIV" and whether, in the past 12 months, they had "taken anti-HIV medicines before sex because you thought it would keep you from getting HIV." In 2017, participants were informed that PrEP is an antiretroviral medicine taken for months or years by a person who is HIV-negative to reduce the risk for getting HIV and then asked whether they had ever heard of PrEP and whether, in the past 12 months they had taken PrEP to reduce the risk of getting HIV.  (Table 1). In 2017, >80% of MSM in 17 of 20 urban areas and in most demographic subgroups were aware of PrEP. From 2014 to 2017, use of PrEP among MSM increased overall from 6% to 35% (aPR = 5.66; 95% CI = 4.85-6.61) and increased in all urban areas and in almost all demographic subgroups ( Table 2). Substantial increases in PrEP use occurred among black, Hispanic, and young (aged 18-29 years) MSM from 2014 to 2017. In 2017, the differences in PrEP use between Hispanic (30%) and white (42%) MSM (aPR = 0.91; 95% CI = 0.78-1.06) and between young (32%) and older (38%) MSM (aPR = 0.97; 95% CI = 0.89-1.05) were no longer significant after controlling for income, health insurance, and region. However, the difference in reported PrEP use between black (26%) and white (42%) MSM remained significant after controlling for these three factors (aPR = 0.78; 95% CI = 0.66-0.92). During 2017, PrEP use increased with education and income, and 39% of the MSM who saw a health care provider in the past 12 months reported PrEP use.

Discussion
From 2014 to 2017, PrEP awareness among MSM in this analysis increased by 50%. More importantly, in 2017, >80% of MSM in all racial and ethnic groups and in 17 of the 20 urban areas were aware of PrEP. This finding is encouraging and suggests that efforts designed to increase PrEP awareness among populations at risk for HIV infection are having a positive impact. These efforts have included media and social marketing campaigns (e.g., Act Against AIDS ¶ ¶ ). In addition, national HIV prevention goals were updated in 2015 to expand efforts to prevent HIV infection using a combination of effective, evidence-based approaches among populations with the highest prevalences of HIV infection, including among black and Hispanic MSM (5). Thus, continued increases of awareness among MSM, especially among black and Hispanic MSM, are expected. Abbreviations: CI = confidence interval; HMO = health maintenance organization. * Men who were at risk for HIV infection and likely to meet clinical indications for HIV preexposure prophylaxis. This was defined as men who had a negative HIV test result at the time of the interview, did not report a previous HIV-positive test result, had either one male sex partner who was HIV-positive or multiple male sex partners in the past 12 months, and reported either condomless anal sex or a sexually transmitted bacterial infection in the past 12 months. † Models adjusted for income, health insurance, and region. § Includes American Indian, Alaskan Native, Asian, Native Hawaiian, Pacific Islander, or multiple races. Although PrEP use by MSM in this analysis increased approximately 500% from 2014 to 2017, only approximately one in three men at risk for HIV infection reported using PrEP. Models examining the impact of PrEP use on incidence predict that the use of PrEP by 30%-40% of MSM with PrEP indications in a community could result in approximately one third of new HIV infections being averted over a 10-year period, with a greater predicted impact if coverage is increased (6). The reported increase in PrEP use among MSM is promising, but higher coverage is needed to reduce incidence of new infections by 90% within the 10 years of the Ending the HIV Epidemic initiative.
The overall impact and efficiency of PrEP at averting new infections is greater in communities with a high prevalence of HIV (7,8).
Therefore, efforts focused on increasing PrEP use among black and Hispanic MSM, who have a higher prevalence of HIV infection (3), might substantially reduce the incidence of HIV infections. The large percentage increases in PrEP use among black and Hispanic MSM in this analysis are promising, but PrEP use in these groups remains low; continued efforts will be needed to meet the goals of the Ending the HIV Epidemic initiative. Because of the structural barriers associated with race that influence access to quality health care (9), demonstration projects for the Targeted Highly-Effective Interventions to Reverse the HIV Epidemic (THRIVE) program*** are underway in seven U.S. cities. These projects establish community *** https://www.cdc.gov/hiv/research/thrive/about.html. collaboratives that provide comprehensive HIV prevention and care services for black and Hispanic MSM. Lessons learned from these efforts might help further inform how best to increase PrEP use among these populations.

TABLE 2. Number and percentage of men who have sex with men who are at risk for human immunodeficiency virus (HIV) infection* and reported using HIV preexposure prophylaxis, by demographic characteristics -National HIV Behavioral Surveillance System, United States, 2014 and 2017
Some health care providers might be missing opportunities to provide PrEP to patients who would benefit from its use. MSM included in this analysis reported behaviors that put them at substantial risk for HIV infection, yet only 39% of those who saw a health care provider in the past 12 months reported using PrEP. CDC's HIV PrEP clinical practice guideline offers comprehensive information to providers for prescribing and managing PrEP and recommends that health care providers take routine sexual histories of all their patients (2). However, some providers only take a sexual history if it is related to the patient's complaint and ask nonspecific questions about sex (10). To increase PrEP use, health care providers might need training and resources to ensure they know how to assess their patients for indications for PrEP and are confident discussing PrEP medication. As part of CDC's Act Against AIDS communication campaign, the Prescribe HIV Prevention program offers an online toolkit to help health care providers use PrEP to prevent new HIV infections among patients at high risk. This toolkit includes resources such as answers to frequently asked questions about PrEP medication and its related clinical care, campaign posters to help raise PrEP awareness, patient materials, a tool to aid health care providers in discussing sexual histories with their patients, and continuing medical education courses on PrEP. To fulfill their critical role in reducing new HIV infections in the United States, health care providers will need to routinely test patients for HIV, link those with HIV infection to care, and discuss HIV prevention options (e.g., condoms and PrEP) with those who are not infected.
The findings in this report are subject to at least six limitations. First, NHBS data do not correspond directly with the criteria for PrEP indication in the clinical guidelines. NHBS uses a 12-month period for assessing risk behaviors versus a 6-month period specified in the clinical guidelines. Second, this analysis used having two or more sex partners in the past year as a proxy for a nonmonogamous relationship, but these partnerships might not have overlapped in time. Thus, the analysis might include some men without indications for PrEP use. Their inclusion in the denominator might underestimate the percentage of men in NHBS using PrEP. Third, different questions were used to assess PrEP awareness and use in 2014 and 2017. The measure of PrEP use in 2017 was more specific than that in 2014, so estimates of PrEP use increases are potentially underestimated. Fourth, NHBS is not nationally representative and might not be generalizable to all cities, nonurban areas, or MSM. Fifth, because data were not weighted to account for the complex sampling methods used to recruit MSM, estimates might be biased by over-or underestimating subgroups of the population. Finally, data on self-reported behaviors might be subject to recall and social desirability biases. Although the impact of recall bias on the analysis is unknown, social desirability bias might lead to overreporting PrEP awareness and use. HIV PrEP awareness and use is increasing in the United States among MSM who are at risk for acquiring HIV, but higher coverage is needed, especially among black and Hispanic MSM, to end the HIV epidemic in the United States by 2030. By routinely testing their patients for HIV, assessing HIV-negative patients for risk behaviors, and prescribing PrEP as needed, health care providers can play a critical role in this effort.

Summary
What is already known about this topic?
Men who have sex with men (MSM) can reduce their risk for human immunodeficiency virus (HIV) infection by using preexposure prophylaxis (PrEP) consistently. Increasing PrEP use is a principal strategy of the Ending the HIV Epidemic initiative.
What is added by this report?
From 2014 to 2017, PrEP awareness among MSM in 20 urban areas increased from 60% to 90%, and PrEP use increased from 6% to 35%. PrEP use increased in almost all demographic subgroups but remains lower among black and Hispanic MSM.
What are the implications for public health practice?
By routinely testing patients for HIV, assessing HIV-negative patients for risk behaviors, and prescribing PrEP as needed, health care providers can play a critical role in ending the HIV epidemic.