Preexposure prophylaxis strategies for African–American women affected by mass incarceration

Objective We aimed to determine the effectiveness of various pre-exposure prophylaxis (PrEP) prescription strategies for African American women impacted by mass incarceration within an urban setting. Design An agent-based model was utilized to evaluate prevention strategies in an efficient, ethical manner. By defining agents, their characteristics, and relationships, we assessed population-level effects of PrEP on HIV incidence. Methods We tested hypothetical PrEP prescription strategies within a simulation representing the African American population of Philadelphia, Pennsylvania. Four strategies were evaluated: PrEP for women meeting CDC indicators regarding partner characteristics, PrEP for women with a recently incarcerated male partner, PrEP for women with a recently released male partner, and couples-based PrEP at time of release. Interventions occurred alongside scale-up of HAART. We evaluated reductions in HIV transmissions, the number of persons on PrEP needed to avert one HIV transmission (NNT), and the resulting proportions of people on PrEP. Results Scenarios prescribing PrEP based on criminal justice system involvement reduced HIV transmissions. The NNT ranged from 147 (couples-based scenario) to 300 (recently released scenario). The percentage of the female population covered by PrEP at any one time ranged from 0.14% (couples-based) to 10.8% (CDC-based). CDC-guideline scenarios were consistently less efficient compared to the justice-involved interventions. Conclusions Expanding PrEP for African American women and their male partners affected by incarceration should be considered in national HIV prevention goals and correctional facilities leveraged as intervention sites. Partner characteristics in the current CDC indications may be more effective and efficient if guidelines considered criminal justice involvement.