Reaching those most at risk for HIV acquisition: Evaluating Racial/Ethnic disparities in the PrEP Care Continuum in Baltimore City, Maryland.

BACKGROUND Reducing HIV incidence requires addressing persistent racial/ethnic disparities in HIV burden. Our goal was to evaluate pre-exposure prophylaxis (PrEP) delivery, overall and relative to community need, among seven clinical sites participating in a health-department led demonstration project to increase PrEP in Baltimore City, Maryland. METHODS PrEP care-continuum stages (screened, indicated, referred, linked, evaluated, prescribed) were examined among HIV-negative individuals receiving services at participating sites between September 30, 2015-September 29, 2019. Community need was defined using information on new HIV diagnoses (2016-2018). Differences in care-continuum progression by demographics/priority population, and comparison of demographic compositions between care-continuum stages and new HIV-diagnoses were examined using modified Poisson regression and Chi-squared tests, respectively. RESULTS Among 25,886 PrEP-screened individuals, the majority were non-Hispanic(NH) Black(81.1%, n=20,998), cisgender-male(61.1%, n=15,825) and heterosexual(86.7%, n=22,452). Overall, 31.1%(n=8,063) were PrEP-indicated, among whom, 56.8%(n=4,578), 15.6%(n=1,250), 10.8%(n=868), and 9.0%(n=722) were PrEP-referred, linked, evaluated and prescribed, respectively. Among 2,870 MSM, 18.7%(n=538) were PrEP-prescribed. Across all groups, the highest attrition was between PrEP-referred and PrEP-linked. NH-Black race (vs. NH-white) was independently associated with lower likelihood of PrEP-prescription [aPR: 0.89; 95% CI:(0.81-0.98) controlling for age/gender]. Relative to the demographic composition of new HIV-diagnoses, fewer NH-Blacks (80.2% vs. 54.3%) and more NH-whites (10.7% vs. 30.3%) and MSM were PrEP-prescribed (55.2% vs. 74.5%). CONCLUSIONS This project showed promise delivering PrEP referrals and prescriptions overall and to MSM. Substantial improvement is needed to improve linkage overall and to decrease disparities in PrEP-prescriptions among NH-Blacks. Future work should focus on addressing service gaps that hinder PrEP utilization.