Research Article: Barriers to HIV pre-exposure prophylaxis among African, Caribbean and Black men in Toronto, Canada

Date Published: March 29, 2019

Publisher: Public Library of Science

Author(s): Alice Zhabokritsky, LaRon E. Nelson, Wangari Tharao, Winston Husbands, Ting Sa, Nanhua Zhang, Jamie Thomas-Pavanel, Shamara Baidoobonso, Rupert Kaul, Dawn K. Smith.


Single-tablet combination emtricitabine/tenofovir is highly effective as HIV pre-exposure prophylaxis (PrEP). Scale-up efforts have targeted men who have sex with men (MSM), but patterns of racial disparities in PrEP use have begun to emerge. African, Caribbean and Black (ACB) communities in Canada and USA are also disproportionately affected by HIV, and there is lack of guidance regarding PrEP implementation in this priority population.

ACB men from Toronto, Canada were recruited in community settings by peers. Participants completed a detailed socio-behavioural questionnaire. Biological samples were collected and tested for sexually transmitted infections. Willingness to accept PrEP was assessed in relation to actual and self-perceived risk of acquiring HIV, as well as demographic and behavioural variables.

424 ACB men were included in the analysis. ACB MSM were more likely to accept PrEP than ACB men only reporting sex with women (MSW; 50.0% vs. 23.6%). The most common reasons for PrEP non-acceptance were concerns regarding side-effects and low self-perceived risk. PrEP acceptance was lowest among younger men (12.5%) and those born in Canada (15.2%). Men with a high self-perceived HIV risk were more likely to accept PrEP (41.3% vs. 22.7% of men with a low self-perceived risk), but only 25.4% of men who were defined as being at high-risk, self-identified themselves as such.

Most ACB MSW were unlikely to accept PrEP, largely due to low self-perceived HIV risk, but PrEP acceptance among ACB MSM was similar to other contemporaneous Toronto MSM communities. PrEP acceptance was particularly low among younger ACB men and those born in Canada. Tailored strategies will be needed to effectively implement PrEP in Toronto ACB communities.

Partial Text

HIV remains an important public health issue, with an estimated 1.8 million new infections worldwide in 2016 [1]. Over the last several decades there have been substantial advances in the fields of HIV prevention and treatment. The development of single-tablet combination antiretroviral regimens has transformed the clinical management of people living with HIV, resulting in excellent virologic suppression, a near normal life expectancy [2], and the virtual elimination of secondary sexual HIV transmission [3,4]. Dual-agent regimens also reduce HIV acquisition risk by over 90% among uninfected, at-risk individuals if taken as pre-exposure prophylaxis (PrEP) [5,6], although efficacy is very dependent on the degree of medication compliance. In February 2016, Health Canada approved the use of a single-tablet combination tenofovir/emtricitabine (Truvada) as PrEP, and the first Canadian guidelines for PrEP have since been published [7]. Several provinces across Canada, including Ontario, have added PrEP to their provincial drug formulary of publicly funded drugs, significantly improving accessibility.

The daily administration of single-tablet combination emtricitabine/tenofovir as PrEP is an effective method to prevent HIV acquisition. MSM communities are most affected by the HIV epidemic in US and Canada, and the majority of PrEP implementation studies have focused on MSM [5,6,21]. However, ACB communities are also disproportionately affected by HIV [6], and much less is known about the acceptability of PrEP in this context, with no prior data from ACB men in Canada. In our community-based study, most ACB men reported being unlikely to use PrEP, although MSM within the ACB community had a similar rate of PrEP acceptance as other MSM in contemporaneous studies [22,23]. Self-perceived risk of acquiring HIV was a significant factor in MSW participants’ likelihood to accept PrEP, with those men who felt they were at high risk for acquiring HIV being more likely take PrEP, but the ability of ACB men to self-assess HIV risk appeared to be sub-optimal.

This community-based study identified challenges with PrEP delivery and uptake among ACB men, the majority of whom reported that they were unlikely to use PrEP. ACB MSW were much less likely to accept PrEP than ACB MSM. Self-perceived risk of acquiring HIV significantly impacted willingness of MSW to use PrEP, but was systematically under-estimated by participants. Taken together, this study informs the development of public health program strategies for PrEP scale-up among ACB men and identifies the need to develop targeted screening tools for these high-risk communities.