COVID-19 has disproportionately affected Black adults, laying bare how racism in health care and society have left Black communities vulnerable to health disparities. Unfortunately, younger Black populations endure other glaring health inequities. A recent study found that Black children are three times more likely to die within a month of surgery as white children. And for years, Black youth have silently shouldered an unequal burden of another widespread and insidious infection: HIV. Latest data from the Centers for Disease Control and Prevention show that Black youth have more than three times the number of new HIV diagnoses than white youth.
While the incidence of HIV nationally has trended downward over the past decade, new infections have risen by over 40 percent among some Black populations. One in 5 of all new HIV infections occur among adolescents and young adults aged 13 – 24 years, with the largest share among Black men who have sex with men. These inequities persist because Black youth are less likely to get tested for HIV and be aware of their infection status. Those who test positive are less likely to engage in medical care, start treatment, and achieve undetectable levels of HIV in their blood, which eliminates infectiousness to sexual partners. While it is easy to blame this snapshot of inequity on individual choices, anti-Black racism — which fuels unequal access to employment, health insurance, and medical care — is the most significant driver of these disparities.
Fortunately, we have a potent tool, known as preexposure prophylaxis or PrEP, that could stem the tide of new HIV infections. With PrEP, a person takes a daily antiretroviral pill (Truvada or Descovy) to prevent HIV acquisition. PrEP reduces HIV transmission from sex by 99 percent and is safe for adolescents. But despite its game-changing potential in HIV prevention, there have been several roadblocks —particularly among Black youth.
The discussion around challenges to accessing PrEP has often plateaued on its high price-tag. Insurance coverage and patient assistance from industry and federal programs offset most expenses, but out-of-pocket costs remain prohibitive for economically-disadvantaged youth. Beyond affordability, however, discrimination, homo-negativity and PrEP-shaming in clinical settings frequently dissuade Black youth from seeking PrEP. Compounded by medical mistrust stemming from atrocities like the Tuskegee Syphilis study and misinformation about PrEP’s safety on social media, adoption of PrEP is paradoxically low in a community with the highest HIV incidence.
Furthermore, Black youth, especially in socially conservative Southern states, are less likely to have access to healthcare that is affirming of their sexual orientation, which also limits opportunities to receive PrEP. Privacy concerns (including nondisclosure to parents or peers) are additional deterrents. And with a backdrop of discriminatory social attitudes, stigma looms large.
A daily pill regimen poses additional challenges for adolescents. Among Black youth who experience poverty, barriers to pill-taking include homelessness, incarceration, and depression. Youth may simply forget to take pills (which is congruent with their developmental stage) or feel uncomfortable keeping the medication at home, as it may compromise discretion around their sexuality. Others have difficulty swallowing pills.
Alternatively, innovative delivery of PrEP could alleviate some of the challenges with daily pills. A recent study demonstrated that cabotegravir, a long-acting injectable medication given every two months, was safe and highly protective against HIV infection among adult men who have sex with men and transgender women. Cabotegravir was statistically superior in protection compared to oral PrEP, though the pills also provided excellent protection.
In surveys, as many as 80 percent of young Black men have indicated hypothetical preferences for injections over daily pills. Bimonthly injections obviate the need for ingesting pills, which could improve adherence, though youth would still need clinical visits to receive injections. Long-acting PrEP would also provide “peace of mind” from missing doses as well as privacy and discretion from not having to store or carry pill bottles in front of family and peers.
A new study is recruiting adolescents in Chicago, Memphis, and Boston to see if the injections are safe and acceptable for minors (enrollment requires parental/guardian consent and assent from youth). Because many young Black men may prefer injections over pills given the unique advantages for this population, this study is an important step forward.
Injectable PrEP alone, however, will not be a panacea to bring PrEP to scale for Black youth. We need to improve access to health insurance and lower out-of-pocket costs. The federal government's Ready, Set, PrEP program provides oral Truvada at no cost to those without prescription medication coverage. Expanding this program will be particularly important in states that did not expand Medicaid, including those in the South where the ratio of PrEP prescriptions to new HIV infections is lowest. A similar program should be authorized for injectable PrEP when it becomes available.
At the same time, social media and public health campaigns tailored to Black communities will be needed to encourage widescale HIV testing and care and destigmatize PrEP. Medical training needs to dedicate more time to sexual health care and reducing stigma. We also need to bring PrEP to youth where they congregate. The "Clinic @ BAGLY" (Boston Alliance of Lesbian Gay Bisexual Queer Transgender Youth) embeds sexual health services (free of charge) in youth-led social programs and prioritizes care for youth of color. Programs like this can provide youth with a means to get PrEP pills or injections discretely and free of cost and stigma. All these efforts — in addition to a new way of administering PrEP — are needed to achieve the federal goal to End the HIV Epidemic by 2030.
We are facing multiple pandemics: COVID-19 and anti-Black racism, which are front and center, and HIV, which is pernicious and persistent. COVID has shed a harsh light on racial inequities in health outcomes, which have existed for years among Blacks in HIV prevention and care, especially among young gay and bisexual men and transgender women. We can make strides in reducing these injustices by investing in all forms of PrEP, improved HIV treatment cascades, and welcoming and accessible health education and care for this community. We invest in COVID to protect our aging. We must invest in HIV prevention to protect our youth.
Lala Tanmoy Das is an MD-PhD student in the Cornell/Rockefeller/Memorial Sloan Kettering combined program in New York City. Dr. Douglas Krakower is an infectious diseases physician at Harvard Medical School and a researcher at Boston's Fenway Health.