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.

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 for PrEP referral when they meet the clinical criteria for PrEP prescription based on CDC guidelines or local protocols. PrEP awareness among persons tested for HIV infection was defined by an affirmative response documented by HIV test providers to the question, “Has the client ever heard of PrEP?” Similarly, PrEP referral among persons eligible for referral was defined by an affirmative response documented by HIV test providers to the question, “Was the client given a referral to a PrEP provider?” PrEP awareness and referrals among Hispanic persons were compared with those of persons of other racial and ethnic groups. PrEP measures among Hispanic persons were also compared by age, gender, race,^†† ethnicity,^§§ test setting, ^¶¶ U.S. Census region,*** and population groups defined by transmission risk.^††† Robust Poisson regression was used to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs). This activity was reviewed and approved by CDC and conducted consistent with applicable federal law and CDC policy.^§§§

During 2019 in the United States, 2,341,342 CDC-funded HIV tests were conducted. These included 546,337 (23.3%) tests conducted among Hispanic persons, 919,066 (39.3%) among non-Hispanic Black/African American (Black) persons, 658,496 (28.1%) among non-Hispanic White (White) persons, and 217,443 (9.3%) among persons of other or unspecified race. Among all tested persons with PrEP-related data, PrEP awareness was slightly higher among Hispanic persons (27.4%) than among Black persons (26.2%; PR = 1.05; 95% CI = 1.04–1.06) but lower than that among White persons (31.4%; PR = 0.87; 95% CI = 0.87–0.88) and those of other racial or ethnic groups (42.1%; PR = 0.65; 95% CI = 0.64–0.66) (Figure).

Among Hispanic persons, awareness was higher among persons aged 25–49 years (29.9%; PR = 1.07) and lower among those aged ≥50 years (17.0%; PR = 0.60) compared with those aged 13–24 years (28.1%) (Table 1). By gender, compared with females, 14.5% of whom were aware of PrEP, awareness was highest among transgender persons (68.6%; PR = 4.74) followed by males (36.6%; PR = 2.53). Awareness was higher among Black Hispanic persons (39.3%; PR = 1.91) and persons of other races (39.3%; PR = 1.91) than among White Hispanic persons (20.6%). Compared with heterosexual Hispanic females (awareness = 17.5%), PrEP awareness was higher among gay, bisexual, and other men who have sex with men (MSM) (63.5%; PR = 3.62), persons who inject drugs (28.9%; PR = 1.65), and heterosexual males (21.5%; PR = 1.22). Awareness was higher among persons tested in non–health care settings (35.4%; PR = 1.95) than among those tested in health care settings (18.1%). By U.S. Census region, PrEP awareness was lower among Hispanic persons tested in the West (49.1%; PR = 0.87), Midwest (30.1%; PR = 0.54), South (13.4%; PR = 0.24), and U.S. territories (12.9%; PR = 0.23) than among those tested in the Northeast (56.2%).

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).

Among Hispanic persons eligible for referral to a PrEP provider, PrEP referral was higher among Hispanic persons aged 25–49 years (22.8%; PR = 1.05) and lower among those aged ≥50 years (16.6%; PR = 0.77) compared with those aged 13–24 years (21.7%) (Table 2). By gender, referral was higher among transgender persons (30.3%; PR = 2.04) and males (25.7%; PR = 1.73) than among females (14.8%). PrEP referral was lower among Black Hispanic persons (13.4%; PR = 0.55) and Hispanic persons of other races (21.6%; PR = 0.89) than among White Hispanic persons (24.3%). PrEP referral was higher among Hispanic MSM (39.5%; PR = 2.57) and persons who inject drugs (17.2%; PR = 1.12) but lower among heterosexual males (11.7%; PR = 0.76) than heterosexual females (15.4%). By test setting, PrEP referral was lower among persons tested in non–health care settings (20.4%; PR = 0.83) than among those tested in health care settings (24.6%). By U.S. Census region, PrEP referral was higher among Hispanic persons tested in the Midwest (32.9%; PR = 2.14), South (26.9%; PR = 1.75), and West (17.8%; PR = 1.16) and lower among those tested in U.S. territories (13.4%; PR = 0.87) compared with persons tested in the Northeast (15.4%).

Acknowledgments

Janet Heitgerd, Lisa Belcher, Euna M. August, Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention; CDC.

Corresponding author: Shubha Rao, [email protected], 404-639-8521.

¹Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC.

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FIGURE. Preexposure prophylaxis awareness and referral to preexposure prophylaxis providers, by race and ethnicity* — United States, 2019^†,§

Abbreviation: PrEP = preexposure prophylaxis.

* Black, White, and persons of other races were non-Hispanic; Hispanic persons could be of any race.

^† Valid HIV tests for this analysis include tests for which a test result (i.e., positive or negative) was known and had a nonmissing value for PrEP awareness and referral.

^§ PrEP awareness among persons tested for HIV infection was defined by an affirmative response documented by HIV test providers to the question, “Has the client ever heard of PrEP?” PrEP referral among persons eligible for referral was defined by an affirmative response documented by HIV test providers to the question, “Was the client given a referral to a PrEP provider?” This analysis excluded HIV tests with missing values on PrEP awareness and referral to a PrEP provider.

Abbreviations: CI = confidence interval; N/A = not applicable; PR = prevalence ratio; PrEP = preexposure prophylaxis; Ref = referent group.
* Valid HIV tests for this analysis included tests for which a test result (i.e., positive or negative) was known and had a nonmissing value on PrEP awareness. PrEP awareness was assessed by HIV test providers documenting a response to the following question, ”Has the client ever heard of PrEP?”
^† For age, the numbers of records missing or invalid are as follows: 3,166 (1.0%) 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.

Abbreviations: CI = confidence interval; N/A = not applicable; PR = prevalence ratio; PrEP = preexposure prophylaxis; Ref = referent group.
* Eligibility for a PrEP referral was assessed by HIV test providers documenting a response to the question, ”Was the client eligible for a referral to a PrEP provider?” Referral to a PrEP provider was assessed by HIV test providers documenting a response to the question, “Was the client given a referral to a PrEP provider?” HIV tests with missing values for eligibility for PrEP referral and referral to a PrEP provider were excluded.
^† For age, the numbers of records missing or invalid are as follows: 552 (0.5%) in the column “Eligible for a PrEP referral” and 163 (0.7%) in the column “Referred to a PrEP provider.”
^§ For gender, the numbers of records missing or invalid are as follows: 419 (0.4%) in the column “Eligible for a PrEP referral” and 116 (0.5%) in the column “Referred to a PrEP provider.”
^¶ 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: 36,654 (32.8%) in the column “Eligible for a PrEP referral” and 7,642 (31.2%) in the column “Referred to a PrEP provider.”
** For population groups, the numbers of records missing or invalid are as follows: 1,747 (1.6%) in the column “Eligible for a PrEP referral,” and 360 (1.5%) in the column “Referred to a PrEP provider.” In addition, the numbers of records for “other” excluded from this table are as follows: 8,294 (7.4%) in the column “Eligible for a PrEP referral” and 1,112 (4.5%) in the column “Referred to a PrEP provider.”
^†† Mobile settings and setting unknown are excluded.
^§§ Includes Puerto Rico and the U.S. Virgin Islands.