2090. The Impact of Structural Racism and Discrimination on the HIV Pre-exposure Prophylaxis Continuum: Evidence from a Systematic Review of the Published Literature

Abstract Background Pre-exposure prophylaxis (PrEP) is an evidence-based intervention shown to effectively reduce HIV infection. However, PrEP is under-utilized, especially among racial and ethnic minority groups where HIV incidence is the highest. Here, we aim to describe the impact of structural racism and discrimination (SRD) on the PrEP continuum. Methods We performed a systematic review of the published literature using MEDLINE database for keywords such as HIV, PrEP, racism, and healthcare disparities. Inclusion criteria were original, U.S.-based studies in English published since 2012. Our main exposure was SRD defined as a socially structured action that is unfair and harms individuals and groups on the basis of race, ethnicity and/or other statuses. Outcome measures included ≥ 1 step of the PrEP continuum. Qualitative analyses were excluded. Results The search returned 297 papers, from which 37 studies met inclusion criteria. SRD was described at the individual level in 1 studies, at the interpersonal in 17 studies, and the societal level in 15 studies with some studies including multiple levels of SRD. In 4 studies, there were no reported differences by race and 1 study reported no differences by neighborhood socioeconomic status. Disparities were observed across each step of the PrEP continuum with Black and Hispanic patients being less likely to have a discussion about PrEP, less likely to receive a PrEP prescription and less likely to adhere or be retained in PrEP care compared to White patients. In two large studies, race-based differences in PrEP prescription were particularly stark: one study with 25,886 patients reported that Black race was found to be an independent factor for non-PrEP prescription and the other with 32,853 patients found that PrEP prescription was 6 times higher among Whites compared to Black patients. Potential mediators to poor PrEP continuum outcomes included perceived healthcare-related discrimination, provider related implicit bias and racial stereotypes, housing instability, food insecurity, insurance status, and history of incarceration. Conclusion SRD at multiple levels contribute to racial disparities across the PrEP continuum. Strategies that reduce SRD may help to mitigate racial/ethnic disparities in PrEP continuum outcomes. Disclosures All Authors: No reported disclosures.