A Patient's Perspective on Privilege as a Prerequisite for PrEP

There were 37,832 HIV diagnoses in the United States in 2018, adding to the 1.1 million people already living with HIV (Centers for Disease Control and Prevention, May 2020). Men who have sex with men (MSM) continue to be the most affected, accounting for 69% of new HIV infections (Jeffries et al., 2020). Young MSM are particularly vulnerable, with 17% of HIV transmissions occurring among MSM ages 13–24 years (Jeffries et al., 2020). The disproportionate burden on young MSM in the HIV epidemic is coupled with underutilization of pre-exposure prophylaxis (PrEP), with a recent Centers for Disease Control and Prevention study showing that only 32% of young MSM surveyed across the United States used PrEP in 2017 (Finlayson et al., 2019). Increasing PrEP uptake and persistence in key populations is a critical objective of the End the HIV Epidemic initiative, with the potential to eliminate 55,828 HIV transmissions over 5 years if uptake is expanded to 40% among PrEP-eligible MSM (Khurana et al., 2018). Current PrEP delivery models place extreme burdens on sexual minority (or queer) adolescents who are trying to access PrEP. Further, privilege creates different paths to PrEP, and marginalized subgroups, such as Black MSM, experience greater barriers (Centers for Disease Control and Prevention, May 2020). These same key populations experience the greatest burden of the HIV epidemic, with one in two Black MSM expected to acquire HIV in their lifetime without intervention (Hess et al., 2017). It is our moral imperative to evaluate what we are demanding from young MSM who enter the HIV prevention continuum, reflecting on trauma experienced along each step.