HIV Preexposure Prophylaxis Awareness and Referral to Providers Among Hispanic/Latino Persons — United States, 2019

Hispanic or Latino* (Hispanic) persons are disproportionately affected by HIV in the United States. In 2019, Hispanic persons accounted for 18% of the U.S. population, but for 29% of new diagnoses of HIV infection (1). The Ending the HIV Epidemic in the U.S. (EHE) initiative aims to reduce new HIV infections by 90% by 2030 (2). Preexposure prophylaxis (PrEP), medication taken to prevent acquisition of HIV, is an effective strategy for preventing HIV infection.† To examine PrEP awareness and referral to providers among Hispanic persons, CDC analyzed 2019 National HIV Prevention Program Monitoring and Evaluation HIV testing data. Approximately one quarter (27%) of Hispanic persons tested for HIV at CDC-funded sites (n = 310,954) were aware of PrEP, and 22% of those who received a negative HIV test result and were eligible for referral (111,644) were referred to PrEP providers. PrEP awareness and referrals among Hispanic persons were lower compared with those among non-Hispanic White persons. Among Hispanic persons, significant differences were found in PrEP awareness and referrals by age, gender, race, population group, geographic region, and test setting. HIV testing programs can expand PrEP services for Hispanic persons by implementing culturally and linguistically appropriate strategies that routinize PrEP education and referral, collaborating with health care and other providers, and addressing social and structural barriers.

Hispanic or Latino* (Hispanic) persons are disproportionately affected by HIV in the United States. In 2019, Hispanic persons accounted for 18% of the U.S. population, but for 29% of new diagnoses of HIV infection (1). The Ending the HIV Epidemic in the U.S. (EHE) initiative aims to reduce new HIV infections by 90% by 2030 (2). Preexposure prophylaxis (PrEP), medication taken to prevent acquisition of HIV, is an effective strategy for preventing HIV infection. † To examine PrEP awareness and referral to providers among Hispanic persons, CDC analyzed 2019 National HIV Prevention Program Monitoring and Evaluation HIV testing data. Approximately one quarter (27%) of Hispanic persons tested for HIV at CDCfunded sites (n = 310,954) were aware of PrEP, and 22% of those who received a negative HIV test result and were eligible for referral (111,644) were referred to PrEP providers. PrEP awareness and referrals among Hispanic persons were lower compared with those among non-Hispanic White persons. Among Hispanic persons, significant differences were found in PrEP awareness and referrals by age, gender, race, population group, geographic region, and test setting. HIV testing programs can expand PrEP services for Hispanic persons by implementing culturally and linguistically appropriate strategies that routinize PrEP education and referral, collaborating with health care and other providers, and addressing social and structural barriers.
CDC analyzed 2019 National HIV Prevention Program Monitoring and Evaluation HIV testing data submitted by 60 CDC-funded state, local, and territorial health departments § and 29 directly funded community-based organizations to assess measures of PrEP awareness ¶ and referral to a PrEP provider.** Persons whose HIV status is negative are eligible ¶ PrEP awareness was assessed by HIV test providers documenting a response to the question, "Has the client ever heard of PrEP (PreExposure Prophylaxis)?" The PrEP awareness question was required from all persons testing for HIV although the response could have been collected before or after the test was performed. ** Referral to PrEP providers was assessed by HIV test providers documenting a response to the question, "Was the client given a referral to a PrEP provider?" Referral was provided if the person testing negative for HIV infection met the appropriate clinical criteria for using PrEP or was determined to be eligible for a PrEP referral based on CDC guidelines or local protocol. Referral to providers in this report might include passive referral (e.g., client is provided information about the PrEP provider) as well as active referral (e.g., client is assisted with contacting and making an appointment with the PrEP provider). Overall, referral to a PrEP provider was higher among Hispanic persons (22.0%) compared with non-Hispanic Black persons (20.8%; PR = 1.06; 95% CI = 1.04-1.07) but lower when compared with non-Hispanic White persons (25.9%; PR = 0.85; 95% CI = 0.84-0.86) and those of other racial/ ethnic groups (25.8%; PR = 0.85; 95% CI= 0.83-0.87) (Figure).

Discussion
Approximately one in four Hispanic persons who received a CDC-funded HIV test was aware of PrEP, and approximately one in five who were eligible for PrEP referral was referred to a  in the column "Tested for HIV infection" and 407 (0.5%) in the column "Aware of PrEP. " § For gender, the numbers of records missing or invalid are as follows: 1,360 (0.4%) in the column "Tested for HIV infection" and 359 (0.4%) in the column "Aware of PrEP. " ¶ Race categories include the following: "White" = Hispanic White; "Black" = Hispanic Black or African American; and "Other" = Hispanic persons of other races including Asian, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and multirace. For race, the numbers of records missing or invalid are as follows: 95,183 (30.6%) in the column "Persons tested for HIV infection" and 35,075 (41.1%) in the column "Aware of PrEP. " ** For population groups, the numbers of records missing or invalid are as follows: 23,002 (7.4%) in the column "Tested for HIV infection" and 3,399 (4.0%) in the column "Aware of PrEP. " In addition, the numbers of records for "other" excluded from this table are as follows: 55,848 (18.0%) in the column "Tested for HIV infection" and 6,654 (7.8%) in the column "Aware of PrEP. " † † Mobile settings and unknown settings are excluded. § § Includes Puerto Rico and the U.S. Virgin Islands.

TABLE 2. Referral to preexposure prophylaxis providers among Hispanic persons who were eligible for PrEP, by demographic characteristics, U.S. Census region, and test setting -United States, 2019
PrEP provider. PrEP use is increasing among Hispanic persons in the United States (3); however, low levels of PrEP awareness and referrals to PrEP providers among Hispanic persons in general and compared with non-Hispanic White persons suggest a need to identify and remove barriers to awareness of, referral to, and receipt of PrEP services. Routinizing PrEP education and referrals, expanding coverage for PrEP medications, and implementing culturally and linguistically relevant strategies might improve optimal and equitable use of PrEP among Hispanic persons at risk for HIV infection (4).
PrEP awareness and referral were higher among Hispanic MSM and transgender persons than among those in other population groups. This finding is consistent with other studies that have documented higher PrEP coverage among MSM and transgender persons (3,5). Given that HIV incidence and prevalence are substantially higher among MSM and transgender persons (1,6), efforts to further increase PrEP awareness and referral among these populations are important to reach persons who might benefit from a PrEP prescription. PrEP referral was lower among Black Hispanic persons compared with that among White Hispanic persons, consistent with lower PrEP coverage among Black persons compared with other racial or ethnic groups (6), suggesting that Black Hispanic persons might experience additional challenges to accessing PrEP services.
Hispanic persons tested in the South and U.S. territories had the lowest levels of PrEP awareness. Communities in the South and U.S. territories are disproportionately affected by HIV (2,6) and have higher need for PrEP services. Low PrEP coverage in the South and other regions is attributed to individual, social, and structural barriers, including lack of health insurance; PrEP-and HIV-related stigma; lower HIV risk perception; limited availability of PrEP services in primary care and sexually transmitted disease clinics and community health centers; and lack of effective messaging about PrEP (7)(8)(9). In addition, immigration status, English language fluency, and education level are barriers to PrEP access among Hispanic persons (8).
PrEP referrals were higher among Hispanic persons tested in health care settings than among those tested in non-health care settings. Health care settings might have routinized referrals to PrEP providers. Health care providers can improve PrEP awareness and use by discussing PrEP benefits, developing culturally tailored messages to destigmatize PrEP, and integrating PrEP into routine primary care (7,9). Establishing linkage agreements with clinical providers and expanding PrEP navigation might increase PrEP referrals in non-health care settings (10).
The findings in this report are subject to at least three limitations. First, data were based on CDC-funded HIV testing programs that were not representative of all U.S. HIV testing programs or persons receiving PrEP care in non-CDC-funded HIV testing programs. Second, data were collected at the test level and might overrepresent persons tested multiple times. Finally, the percentages of Hispanic persons who were aware of PrEP and those referred to a PrEP provider might be overestimated because missing records were excluded from the denominators.
Broader implementation of PrEP services among Hispanic persons at risk for HIV infection is an essential strategy of the EHE initiative (2). CDC has developed an integrated HIV prevention campaign, Let's Stop HIV Together/Detengamos Juntos el VIH, ¶ ¶ ¶ featuring messaging and resources to increase PrEP awareness and use among Spanish speakers. In addition, the Ready, Set, PrEP**** program provides free PrEP medication to eligible persons. HIV prevention programs can help achieve the goals of the EHE initiative by addressing individual, social, and structural barriers to receipt of PrEP services, collaborating with health care and other providers, expanding health care coverage, and implementing culturally and linguistically relevant strategies for Hispanic persons. ¶ ¶ ¶ https://www.cdc.gov/stophivtogether/index.html?CDC_AA_ refVal=https%3A%2F%2Fwww.cdc.gov%2Factagainstaids%2Fabout%2 Findex.html **** https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/ prep-program

Summary
What is already known about this topic?
Hispanic or Latino (Hispanic) persons are disproportionately affected by HIV. Preexposure prophylaxis (PrEP) is an effective strategy to prevent HIV infection.
What is added by this report?
Approximately one in four Hispanic persons tested for HIV at CDC-funded sites was aware of PrEP, and 22% of those eligible for referral were referred to PrEP providers. PrEP awareness and referrals among Hispanic persons were lower compared with those among non-Hispanic White persons.
What are the implications for public health practice?
HIV testing programs can expand PrEP services for Hispanic persons by implementing culturally and linguistically appropriate strategies that routinize PrEP education and referral, collaborating with health care and other providers, and addressing social and structural barriers.