Although new HIV diagnoses in New York City (NYC) continue to decline, sociodemographic disparities persist among those newly diagnosed. In 2015, the greatest burden of new HIV diagnoses in NYC was borne by blacks (42%), Hispanics (36%), and men who have sex with men (MSM) (58%). Blacks and Hispanics constituted 61% and 30%, respectively, of new diagnoses among women in 2015 and accounted for 31% and 42%, respectively, of new diagnoses among MSM.1
In the past 5 years, HIV prevention has evolved to focus on combination prevention strategies that include treatment to suppress HIV viral load in infected persons and reduce transmission efficacy, and postexposure and preexposure prophylaxis (PEP and PrEP) using antiretrovirals (ARV) to prevent new infections, along with condom use to prevent HIV and other sexually transmitted infections.2 After the 2012 FDA approval of tenofovir-emtricitabine for daily PrEP to reduce HIV infection in adults, the Centers for Disease Control and Prevention (CDC) released recommendations in 2014, that PrEP be considered a prevention option for individuals at higher risk of HIV.3 In NYC, the Department of Health and Mental Hygiene (DOHMH) has implemented consumer and provider educational campaigns since 2014 to enhance PEP/PrEP awareness and promote HIV prevention through a combination of PEP/PrEP, condoms, and HIV treatment. These interventions align with the New York State (NYS) Plan to “End the Epidemic” (EtE) through the expansion of testing, treatment, and prevention, one goal of which is to facilitate access to PEP/PrEP for persons at high risk of HIV acquisition.4
The HIV Field Services Unit (FSU) at the NYC DOHMH assists HIV-diagnosed persons with partner services (PS) and linkage to care (LTC). Persons needing FSU services are identified by provider report, the NYC Surveillance Registry, or HIV-infected individuals requesting assistance with PS and/or LTC from DOHMH Disease Intervention Specialists (DIS). PS entails the elicitation of HIV-exposed sex- or needle-sharing partners, partner tracing, notification, HIV testing, and LTC of newly HIV-diagnosed partners. In NYC, 2015, of 1971 cases assigned for PS and LTC by the FSU, 1676 (85%) were interviewed; 833 (50%) named partners. A total of 1108 partners were elicited, an average of 2 partners for every 3 interviewed cases. Fewer than 20% named more than 1 partner. Of elicited partners, 533 (64%) were eligible for notification; 400 (75%) were notified. Those ineligible were previously HIV positive, deceased, out of jurisdiction, or had domestic violence (DV) issues; those eligible but not notified were predominantly not located (97%) with a small proportion refusing notification (2%). Among notified partners, 215 (54%) underwent HIV testing; 37 (17%) were HIV positive. DIS provide HIV prevention education, resources (print/web-based), and condoms to all patients and partners. Starting November 2015, these efforts included referrals to PEP/PrEP providers.
Although the efficacy of chemoprophylaxis in preventing new HIV infections has been clinically established,5–8 its success depends on awareness, uptake, and adherence among persons at high risk of HIV acquisition. Named partners of HIV-positive individuals are a particularly vulnerable group given their known HIV exposure. Understanding PEP/PrEP awareness and use in this population is key to targeting campaigns, addressing barriers, and enabling scale-up. The FSU collects information on PEP/PrEP awareness and use to assess needs and constraints of notified partners in relation to their HIV risk reduction and uses it to develop outreach strategies. We present findings from the first 2 years of program data on PEP/PrEP awareness, discussion with provider, and use among notified partners of HIV-positive individuals.
Partner Elicitation, Notification, and Testing
Partner elicitation involves eliciting partner name, date of birth/age, physical description, contact information, partner type (sex/needle sharing), and exposure period to enable partner tracing and notification. DV screening is conducted by DIS or provider for all partners. If no DV risk is identified, the DIS discusses a notification plan with the index patient for each partner elicited, including options for FSU notification, dual notification (index notification in the presence of DIS/medical provider), index notification, or provider notification. If there is risk of DV, notification is deferred until DV issues are resolved. After locating the partner and verifying their identity, the DIS conducts notification, either in person or by telephone, text, or email using a standardized script. Up to 3 contact attempts are made, through various methods, before a partner is deemed “unable to locate.” Confidentiality of HIV-related information is communicated to the partner; no information about the index is divulged. The partner is offered postnotification HIV testing, as well as a follow-up test in 8–12 weeks if the exposure is determined to be within the window period. For partners notified and/or tested by a provider, DIS attempt to verify notification and/or HIV results. Notification outcomes are never communicated to the index.
Data Sources and Variables
This analysis is based on routinely collected data from newly HIV-diagnosed index patients and their named partners, from January 2015 to April 2017. DIS capture partner information on a standard electronic Partner Investigation Form during partner elicitation and notification. The Partner Investigation Form documents partner's sociodemographics, partner type (mutually exclusive categories of sex-, needle-sharing, or sex- and needle-sharing partner), if partner is a spouse, and condomless anal intercourse (CAI), as reported by the index, and postnotification HIV testing outcomes. An index or their named partners may also identify persons who would benefit from HIV testing—“social network (SN) partners”—who are not ascribed a partner type. Partner's current gender, race/ethnicity, and age are collected primarily for purposes of partner identification and in some, but not all cases, verified by partner self-report. We created mutually exclusive categories of “MSM sex partners,” “heterosexual sex partners,” “needle-sharing partners,” and “SN partners” by combining partner gender and partner type with the corresponding index's gender.
Awareness of PEP/PrEP, whether partner discussed PEP/PrEP with a provider, who (provider or partner) initiated the discussion, and previous/current use of PEP/PrEP are captured through partner self-report during notification, testing, or verification.
Data are stored and managed in a secure environment using data security and confidentiality protocols in place for FSU and HIV surveillance.
We conducted univariate and bivariate analyses of partners having heard of PEP/PrEP (“awareness”), discussed PEP/PrEP with a provider (“discussion”), and used PrEP (“use”), by partners' age (categorized into age groups of ≤30 years and >30 years, based on median), race/ethnicity, gender, whether partner was a spouse of the index, partner type, index-reported CAI, and provider discussion of PEP. Statistical significance of differences among groups was assessed using the χ2 test or the Fisher exact test (alpha = 0.05).
We examined differences in postnotification HIV testing among notified partners and HIV test result among tested partners, by PEP/PrEP awareness, discussion, and use.
We constructed 2 multivariate logistic regression models using step-wise backward elimination to generate adjusted odds ratios (aORs) and their 95% confidence intervals (CIs) of partners' awareness of PEP (model 1) and PrEP (model 2), respectively. In addition, we conducted multivariate analyses for PEP/PrEP discussion and PrEP use. Because partner's current gender was used to create the variable for sex partner type (MSM versus heterosexual), we did not control for both variables in the same model.
We did not conduct bivariate or multivariate analyses of PEP use because of the small number of PEP users (n = 14). Data were managed and analyzed using SAS 9.3 (SAS Institute Inc., Cary, NC).
Our findings are based on data from 621 partners elicited, January 2015–March 2017 and interviewed, May 2015–April 2017. In the elicitation period, 1876 index patients named 2444 partners, 1626 were eligible for notification, and 1311 partners were notified. The FSU conducted 1028 in-person/phone notifications, 271 HIV tests, and 206 verifications. A total of 956 partners were approached for PEP/PrEP questions; 335 refused to respond. The 159 partners not approached were notified/interviewed before May 2015 when the PEP/PrEP questions were launched (Fig. 1).
The majority of partners reported their gender as male (71%). Median age was 34 years (interquartile range: 17). Blacks constituted 38% of partners and Hispanics and whites made up 31% and 12%, respectively. In partner type, 47% were MSM and 48% heterosexual sex partners, 5% were SN partners; only 1 was a needle-sharing partner. Index-reported CAI was 31% for partners overall and 56% for MSM sex partners.
Figure 2 describes overall PEP/PrEP awareness, discussion, and use. Partners who had heard of PEP comprised 34%, and of PrEP, 44% of partners. Provider-initiated discussion of PEP was reported by 18%, and of PrEP by 24% of partners, whereas 13% reported initiating the discussion on PEP and 16% on PrEP. Only 2% of partners reported PEP use; 14% reported using PrEP.
Postnotification HIV testing was conducted for 52% (n = 322) of partners. New HIV diagnoses constituted 6% (n = 19) of tested partners. PrEP awareness and PEP/PrEP use were associated with partner testing. HIV testing was lower among partners who had heard of PrEP (47% versus 56%), used PEP (23% versus 56%), and used PrEP (42% versus 58%). PEP awareness and PEP/PrEP discussion and use were associated with HIV test results. HIV-positive results constituted 2% of partners with PEP awareness versus 8% among those with no PEP awareness. There were no HIV-positive results among partners reporting PEP/PrEP provider discussion or use.
PEP Awareness and Provider Discussion
Table 1 describes partners' awareness and discussion of PEP, by sociodemographics, partner type, and index-reported CAI.
PEP awareness was 39% among male partners versus 22% among female. Only 30% of black and 36% of Hispanic partners had heard of PEP versus 51% of whites. PEP awareness was 53% among MSM versus 18% among heterosexual sex partners and 22% among SN partners. Among those with index-reported CAI, PEP awareness was 50% versus 26% among partners with no index-reported CAI.
PEP provider discussion differed by partner type, being highest among SN partners (53%), followed by MSM (48%) and heterosexual sex partners (36%).
PrEP Awareness, Provider Discussion, and Use
Table 2 describes partners' PrEP awareness, discussion, and use by sociodemographics, partner type, index-reported CAI, and provider PEP discussion.
PrEP awareness was 50% among male partners versus 31% among female, 38% among black partners, 44% among Hispanics, and 65% among whites. In partner type, 65% of MSM had PrEP awareness versus 26% of heterosexual sex partners and 21% of SN partners. Of partners with index-reported CAI, 62% had PrEP awareness versus 34% among those with none.
More partners who reported PEP provider discussion had PrEP awareness than those who did not (64% versus 45%).
PrEP was discussed by 43% of black and 55% of Hispanic partners versus 69% of whites, and by 59% of MSM versus 42% of heterosexual sex partners. Provider discussion of PrEP was reported by 95% of partners reporting a provider PEP discussion versus 19% among those not.
PrEP use was reported by 23% of male and 6% of female partners; by 12% of black, 20% of Hispanic, 32% of white, and 35% of partners of other race/ethnicities. MSM sex partners reported highest PrEP use (27%), followed by SN partners (19%) and heterosexual sex partners (7%). PrEP use was higher among partners with index-reported CAI than among those with none (30% versus 13%), and among partners reporting a provider PEP discussion than among those who did not (25% versus 12%).
PEP Awareness: Independent Predictors
Table 3 shows crude and aORs (model 1) of partners' PEP awareness.
After adjusting for covariates, only partner type predicted PEP awareness. The odds of PEP awareness were 4 times greater among MSM than those among heterosexual sex partners (aOR: 4.21; 95% CI: 2.10 to 8.44).
PrEP Awareness: Independent Predictors
Table 3 shows crude and aORs (model 2) of partners' PrEP awareness. In the adjusted model, race/ethnicity and partner type were independently associated with PrEP awareness. Black and Hispanic partners had 66% (aOR: 0.34; 95% CI: 0.15 to 0.75) and 63% (aOR: 0.37; 95% CI: 0.17 to 0.84) lower odds of PrEP awareness, respectively, than white partners. The odds of PrEP awareness were almost 5 times greater among MSM than those among heterosexual sex partners (aOR: 4.60; 95% CI: 2.38 to 8.87).
Provider PEP/PrEP Discussion and Use: Independent Predictors
Provider PEP discussion and PEP use were independently associated with partner type, after adjusting for age and race/ethnicity. The odds of provider PEP discussion were almost twice as high among MSM as heterosexual sex partners (aOR: 1.58; 95% CI: 1.01 to 2.48). By contrast, the odds of PEP use were 93% lower among MSM than those among heterosexual sex partners (aOR: 0.07; 95% CI: 0.01 to 0.56) (Results not shown).
Provider PrEP discussion was independently predicted by race/ethnicity after adjusting for age, partner type, and index-reported CAI. Black partners had 66% lower odds (aOR: 0.34; 95% CI: 0.16 to 0.73) than whites of reporting a provider PrEP discussion (Results not shown).
PrEP use was independently predicted by provider PEP discussion. The odds of PrEP use were twice as high among partners reporting provider PEP discussion as among those who did not (aOR: 2.03; 95% CI: 1.08 to 3.82) (Results not shown).
FSU Partners: A PEP/PrEP Priority Population
Partners elicited from HIV-positive individuals constitute a priority population for HIV prevention, given their exposure history and contact with HIV-diagnosed persons. Assessment of awareness and use of PEP/PrEP in this group is critical. Collection of this information also provides an entry for DIS to offer partners resources and referrals to PEP/PrEP providers.
Our data show low levels of awareness, provider discussion, and use of PEP/PrEP among notified partners of HIV-positive index patients. Only one-third of partners notified between May 2015 and April 2017 had heard of PEP and less than half had heard of PrEP. These findings reveal possible gaps in ongoing prevention messaging and its limitations in reaching vulnerable populations.
Lower PrEP Awareness Among Black and Hispanic Partners
PrEP awareness was lower among black and Hispanic partners than that among whites. Studies conducted by the NYC DOHMH confirm that race/ethnicity is a determinant of PrEP awareness in NYC. An online survey found PrEP awareness among NYC MSM in 2014 at 81%, but lower among black (69%) and Hispanic (73%) MSM than among white MSM (89%). After adjusting for age, education, and survey year, the odds of PrEP awareness remained lower among black MSM than those among whites.9 A 2013 study conducted among women of color found that only 11% of black women and 17% of Hispanic women surveyed had heard of PrEP.10
Black and Hispanic communities in NYC and elsewhere in the United States are disproportionately affected by HIV. In 2014, 44% of estimated new diagnoses in the United States were among blacks and 23% among Hispanics who represent only 12% and 16% of the population, respectively.11,12 In 2013–2014, LTC within 90 days of HIV diagnosis among blacks nationally was 45%, and among Hispanics, 61%, a long way from the 85% goal set by the 2010 National HIV/AIDS Strategy.13 Young black MSM in the United States are heavily affected by HIV,14 are least likely to test regularly, and to have access to HIV care; they consequently have lower survival rates than their Hispanic and white counterparts.15 Disparities in testing and treatment extend to the adoption of prevention strategies; PrEP uptake is lower among black MSM than that among whites.16 Medical mistrust, discomfort with discussing sexual behavior with providers, perceived or experienced stigma, high cost, inadequate health insurance, and access to health care create individual, community, and structural-level barriers to utilization, exacerbating disparity.17–19 Increasing PrEP uptake will involve efforts to increase knowledge of its benefits and limitations in socially appropriate ways, particularly for black and Hispanic communities. These would entail dealing with misconceptions, alleviating community-level and structural barriers to access, and enabling conversations on sexual behaviors and prevention modalities with health care providers.20,21
Enhancing Provider Training and Sensitization
Only 1 in 5 partners in our analysis reported a provider-initiated PEP discussion; 1 in 4 reported a provider-initiated PrEP discussion. Black partners were less likely than whites to report any provider PrEP discussion. Optimal uptake of PEP/PrEP hinges not only on educating communities at risk but also on enhancing health care providers' knowledge of PEP/PrEP, guidelines for evaluation, and willingness to prescribe. A national annual survey of US clinicians found that in 2015, 66% had PrEP awareness, but only 7% reported prescribing PrEP, and in 2014, only 17% reported reading the CDC PrEP guidelines.22 Studies show that providers may be less likely to prescribe PrEP to high-risk heterosexuals and injection drug users than to MSM, and that provider perception of greater risk compensation among black patients may lead to reduced willingness to prescribe.23,24 A 2015–2016 study of NYC providers visited by an NYC DOHMH PEP/PrEP provider outreach campaign found that only 44% had a PrEP protocol, 55% had ever prescribed PrEP, and among these, only 61% fully adhered to CDC PrEP guidelines.25 Our findings support previous research in indicating the need for enhanced training and sensitization of medical providers on PEP/PrEP, including how to evaluate patients from various backgrounds for this intervention.
Importance of PEP
Although PrEP is a recent biomedical intervention, the use of PEP for nonoccupational HIV exposure is an established practice.20,26 PEP is an important emergency strategy for individuals who use condoms consistently but experience a lapse or malfunction. In our data, postnotification HIV-positive test results were twice as high among partners with no PEP awareness as among those who had heard of PEP. However, PEP awareness and use remain suboptimal among populations at risk.20 Only one-third of partners in our data had heard of PEP or discussed it with a provider; 1 in 50 reported PEP use, although CAI was index reported for 1 in 3. Measuring PEP awareness and use remains an important component of FSU PS and prevention efforts because previous PEP use is associated with PrEP use and intent to use.20,27 Access to timely PEP can not only avert HIV infection after a recent exposure but also provides a point of transition to PrEP through provider discussion and evaluation.28,29 Education on self-recognition of risk behavior and of potential exposure to HIV infection and access to resources to seek timely ARV chemoprophylaxis are key to ensuring that those in need of PEP may receive it and may subsequently be evaluated for transition to PrEP.20
The first limitation of our analysis arises from the nature of partner data. Unlike HIV-positive individuals whose data are collected for surveillance purposes at multiple points, including medical records, provider report forms, and during PS and LTC efforts, partners do not enter the surveillance mechanism unless they are HIV diagnosed. Sociodemographic information is therefore often incomplete for HIV-negative/untested partners and, when completed, may be imprecise due to third-party report and inconsistent verification. Self-reported information on risk behavior is not collected from partners; the only available data on this come from index report.
Incomplete or missing information on key variables diminishes sample sizes, leading to loss of statistical power in adjusted models. The data may also suffer from social desirability and recall biases inherent in self-report. Finally, our findings are restricted to named partners of HIV-positive individuals traced and notified by FSU DIS, and therefore not generalizable to the larger population of individuals at risk of HIV infection.
Implications for Interventions
The NYC DOHMH has been disseminating comprehensive HIV prevention messages to the public since 2014, including a multimedia campaign “PrEP and PEP: New Ways to Prevent HIV” focused on reaching populations at increased HIV risk such as gay and bisexual men, transgender women, and serodiscordant couples30,31 and the “#PlaySure” media campaign (and accompanying safe sex kit) to enhance awareness of and promote HIV prevention through a combination of PrEP, condoms, and HIV treatment.31,32 In addition, public health detailing on PEP/PrEP with NYC providers was initiated in 2014.31 Programs to improve consumer knowledge and access to PEP/PrEP, as well as provider trainings, continue to be planned and launched.
The FSU has incorporated referrals to PEP/PrEP providers and distribution of PEP/PrEP information into routine PS HIV prevention activities for partners and index patients. Although educating HIV-negative/untested partners on the range of prevention modalities and their importance is key to their own ongoing HIV risk reduction, index patients constitute an important point of intervention for combination prevention options for their HIV-negative partners. The perception of being at risk of transmitting HIV to a partner has been shown to predict willingness of an index to recommend PrEP to an HIV-negative partner.33 The support and acceptance of the index can potentially enable timely initiation of ARV chemoprophylaxis for a partner, adherence to the medication regimen, and may reduce sexual risk behaviors.34
Heterosexual sex partners comprised over half the partners in our data and had lower PEP/PrEP awareness than MSM sex partners. HIV prevention messaging should address various populations to minimize misconceptions that PrEP is more suited for certain groups at risk than others. Furthermore, given the burden of new HIV diagnoses borne by blacks and Hispanics in NYC, our finding that partners from these communities are least likely to have PrEP awareness and provider discussion, signals the need to further target local efforts and comprehensive prevention interventions and to limit the perpetuation of disparities in PEP/PrEP use. To be successful, PEP/PrEP messaging must continue to be designed in culturally relevant ways, with images and language that specific groups can identify with, and must speak to both HIV-negative individuals at risk and persons living with HIV.20 Prevention messages must simultaneously avoid creating the impression that only particular groups are at risk of HIV infection—a balance that often proves challenging to achieve.
The authors thank Sarah Braunstein, PhD, MPH, Demetre Daskalakis, MD, MPH, Julie Myers, MD, MPH, Kent A. Sepkowitz, MD, MPH, and James Hadler, MD, MPH for substantive comments on the draft manuscript, Yasmin Ramos and Sharmila Shah, MPH for assistance with data quality assurance, and Jamie S. Huang, MPH and Anthony S. Romano, MPH for editorial assistance.
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