Background: Increasing PrEP uptake while ensuring health equity is critical to reach Ending the HIV Epidemic goals. At Baltimore City Health Department (BCHD) Sexual Health Clinics (SHCs), we investigated disparities in PrEP discussions and prescriptions among demographic groups and risk categories over three time periods: 2016-2019, program establishment and scale-up; 2020-2021, COVID-19-impacted; 2022-2023, expansion of rapid PrEP and targeted provider feedback concerning missed opportunities for PrEP discussions.

Methods: We utilized routinely collected patient demographic, sexual history, substance use, clinical, and treatment data from electronic health records at BCHD SHCs. The "priority for PrEP initiation" group was based on clinical and epidemiologic indications for PrEP. Relative differences in 1) patient-clinician discussions about PrEP and 2) PrEP prescriptions, across the three time periods, were analyzed using multivariable regression.

Results: We observed 8672 priority patients over eight years. PrEP discussions increased from 42% to 70%. Regression identified significantly lower discussions among cis women, straight cis men, and MSM age ≥30 in all time periods, but magnitudes of disparities decreased over time. Prescriptions among all priority patients increased from 14% to 34% over time. Compared with Black MSM age <30, we observed significantly more prescriptions among non-Black/non-Latino MSM (+29%) and Latino MSM (+60%) in 2016-19. By 2022-23 the disparities lost statistical significance for non-Black/non-Latino MSM and decreased for Latino MSM.

Conclusions: Expansion of access to PrEP and usage of 'priority patient' criteria for PrEP initiation, along with direct feedback to clinicians, was associated with decreased disparities in 1) PrEP discussions overall and 2) prescriptions among MSM.