Disparities in PrEP Eligibility and Uptake at the Intersection of Sexual Identity and Behavior: Results from a Federally Qualified Health Center in Chicago

Introduction Use of pre-exposure prophylaxis (PrEP) is an effective biomedical intervention contributing to Ending the HIV Epidemic (EHE) in the USA. However, PrEP effectiveness is hindered by inadequate uptake among populations vulnerable to HIV. This study examines the relationships between sexual behavior/identity and PrEP eligibility and uptake while controlling for race/ethnicity (given evidence of racial/ethnic disparities in PrEP eligibility and update). Methods Data for this study were collected between 2012 and 2020 from the electronic medical record (EMR) from a Federally Qualified Health Center (FQHC) in Chicago. A series of bivariate and four parallel logistic regressions (one each for transgender women, cisgender women, transgender men, and cisgender men) were conducted to examine factors associated with PrEP eligibility, controlling for race/ethnicity. Two additional regressions examined PrEP uptake—measured by first and second prescription outcomes—among cisgender men. All models controlled for age, monthly income, year of initial appointment, and primary clinic location. Results Gay/lesbian cisgender women who have sex with men only (WSMO) were less likely to be eligible for PrEP than their heterosexual WSMO counterparts. Bisexual and heterosexual cisgender women who have sex with men and women (WSMW) were more likely to be eligible for PrEP than heterosexual cisgender WSMO. Gay/lesbian cisgender WSMO were less likely to be eligible for PrEP than those cisgender WSMO who identified as heterosexual. Regardless of sexual identity, men who have sex with women only (MSWO) were less likely to be eligible for PrEP than men who have sex with men only (MSMO). Heterosexual cisgender MSMO and men who have sex with men and women (MSMW) were less likely to be eligible for PrEP compared to their gay cisgender MSMO peers. Compared to gay cisgender MSMO, gay and bisexual cisgender MSMW were more likely to be eligible for PrEP. Similarly, among cisgender men, those who did not identify as gay were significantly less likely to receive a first PrEP prescription compared to gay MSMO with odds of receiving a second PrEP prescription being lower for bisexual MSMW, and heterosexual MSMW and MSWO compared to gay MSMO. Moreover, among transgender women and transgender men, both Latinx and Black patients were more likely to be eligible for PrEP than their White counterparts. However, for cisgender men, both Latinx and Black patients were less likely than their White peers to be eligible for PrEP. Conclusions Although assessment of PrEP eligibility relies on a number of criteria, the former CDC guidelines emphasized sexual behavior, particularly the gender(s) of sexual partners, as the most salient focus, our findings highlight the missed opportunities of not also including sexual identity in prior guidelines. While the new CDC guidelines use a more holistic approach to eligibility, assessment of sexual identity and behavior at intake are key to ensuring culturally appropriate and inclusive messaging. Policy Implications PrEP eligibility criteria should be revisited and revised, particularly for cisgender and transgender women, who are frequently missed by current guidelines. Also, more attention is needed to ensure that advertisements and clinical encounters do not perpetuate monosexist viewpoints, including bisexual erasure.