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J Natl Med Assoc. 2018 Oct;110(5):480-485. doi: 10.1016/j.jnma.2017.12.006. Epub 2018 Feb 1.

Engaging United States Black Communities in HIV Pre-exposure Prophylaxis: Analysis of a PrEP Engagement Cascade.

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Philadelphia Department of Public Health, Division of Ambulatory Health Services, 500 South Broad St., Philadelphia, PA 19146, USA. Electronic address:
Philadelphia Department of Public Health, Division of Ambulatory Health Services, 500 South Broad St., Philadelphia, PA 19146, USA.
AIDS Care Group, 907 Chester Pike, Sharon Hill, PA 19079, USA.



National PrEP utilization analyses show US non-Hispanic Blacks accessing PrEP at disproportionately low rates given the higher HIV prevalence among Blacks, and in comparison to utilization by non-Hispanic Whites. Women also are underrepresented among PrEP utilizers, especially Black women. We examine the process of accessing PrEP for a majority Black population in an urban community health center setting.


In the Philadelphia city health centers, patients referred for PrEP were followed through six steps of accessing PrEP: referral, patient contact by a PrEP team, maintained interest by patients, scheduling of screening appointments, attending screening appointments, and initiating PrEP. Chi-squared tests were performed at each stage to identify gender differences in drop-off at each step.


Between August 2014 and December 2015, 14% of 785 patients referred for PrEP initiated. Women constituted 37.8% of referrals. A smaller majority of Blacks initiated (84.6% of females, 69.5% of males) than were referred (94.5% of females, 88.1% of males). Prior knowledge of PrEP was associated with screening (68% of those with prior knowledge screened, compared with 29.6% of those without prior knowledge,Χ2 p<0.0001). Higher initiation:referral ratios were noted for self-referrals, and for those referred by clinicians, peers and partners.


In a diverse cohort in a community health center setting, myriad barriers resulted in a 14% initiation rate for persons at elevated risk for HIV who were referred for PrEP. These barriers led to disproportionately fewer non-Hispanic Blacks and women initiating PrEP. Efforts to better engage Blacks and women in PrEP care are urgently needed, and may include better dissemination of PrEP-related information in Black communities and to women, and training of clinicians serving Black and female populations to improve competency in provision of PrEP care.


Black; Cascade; Engagement; HIV; PrEP


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