番茄社区

番茄社区 brought together three expert leaders for a virtual roundtable discussion on HIV news from the IDWeek annual meeting: Moderator , of the University of California San Francisco, is joined by , of the University of Virginia School of Medicine in Charlottesville, and , of the University of California San Diego School of Medicine.

This final of four exclusive episodes discusses racial and sex disparities in the use of pre-exposure prophylaxis (PrEP) among U.S. veterans, as well as an interventional study that seems to be successfully increasing PrEP uptake overall. You can view other videos in this series here.

Following is a transcript of the discussion:

Gandhi: I think we should end with PrEP because there was some PrEP abstracts that were interesting.

McManus: Yeah, so one of the ones that I think really stuck out was the . So that's looking at the VA system; that's a system where their access should be equal. And so unfortunately -- on one hand they did see increases in PrEP-to-need ratio, so they did see that people who needed PrEP were more likely to get it over time when they looked just from 2019 to 2022, so that's encouraging -- but they did unfortunately see both sex and race group differences. And so that's something that we don't want to be seeing in a setting like this where access should be more equal than kind of the U.S. healthcare system at large.

And so I think there were some bright spots that actually in the West and in the Northeast, the racial disparities actually went away over that time period. So it'd be interesting to know what were the VAs in those regions doing and were they doing something different that the other VA systems can learn from? And then overall, trying to think about how -- in the places where we didn't see the disparities decrease -- how can they increase PrEP uptake among women as well as among the different...mostly it was Black people who had lower rates in the other areas. So specifically the Midwest and the South kind of thinking about what should the VA systems in those regions do.

Gandhi: But it's such a great point because when we saw from Patrick Sullivan at IAS [International AIDS Society] -- we were all really surprised and not surprised -- but that was in a non-VA setting. And if a VA setting is a closed system, then it really makes you think that there's bias in the providers and who they choose to give it to. And that I think is kind of hopeful because hopefully that kind of bias can be trained out of -- that people can be still at risk, obviously if they're women. And so I thought it's a really good point that the VA analysis is very unique.

Bamford: And any increased stigma in different regions because, like you said, it shouldn't be an access issue. And so for some reason either patients aren't asking or they're not being offered in certain parts of the country.

McManus: The other thing was there was a VA study, I think it was at IDWeek a few years ago, that actually looked at self-perception of risk and that was very low or discordant with true risk. And so that would be another thing to think about, is it that people are not also perceiving their true risk in certain areas of the country? Or how can we think about bias, stigma, and then making sure that people understand their risk?

Gandhi: And provider education and patient education and community-based patient education.

There was a bright spot though on the PrEP front, because I thought that was really amazing. They call it SNAPS, their program, which is very snappy and it stands for a really intense program at NYU at Bellevue, which is a relatively publicly-insured population -- surveillance, navigation, acceleration, point-of-care PrEP counseling, and seamless comprehensive longitudinal care -- those are the five of the acronyms. But there was a lot of work to start PrEP in what we think are non-traditional settings like emergency departments. And they really increased PrEP uptake in these groups that we just talked about, in women, Black patients, Spanish-speaking patients. So I wondered it felt like this was something that was doable.

McManus: I thought it was definitely encouraging. I thought it was also interesting, like you said, they increased PrEP uptake in the groups that we want to see it increase. And in some areas the PrEP uptake went from 0% to 50%, so they really were able to reach people.

Gandhi: That's an infinity increase if you divide by zero.

Bamford: It seems like they chose these clinical settings based on STI [sexually transmitted infection] testing. And so, back to the education and perceived risks, it really requires more provider education to see. But you're here for STI testing, clearly you perceive yourself at risk for STIs. Well, HIV is an STI also, and you would be a great candidate for PrEP too.

Gandhi: So I think we're ending on a hopeful note. Long-acting comorbidities means screen. We have interventions for weight now, which [we] can't get them, but we have them. And then we have this hopeful note on PrEP and then we will all go into CROI [Conference on Retroviruses and Opportunistic Infections] next with armed with this data. So it was really nice to talk with both of you today.

Bamford: Yeah, thank you. Yeah, this was really great. Really great session.

Gandhi: Thank you.

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