Abstract
IntroductionDespite the efficacy of pre-exposure prophylaxis (PrEP) in preventing HIV transmission, few studies have evaluated PrEP use and retention in care outcomes in real-world settings outside of clinical trials.MethodsData were collected from PrEP clinical care programmes in three mid-size US cities: Providence, Rhode Island (RI); Jackson, Mississippi (MS); and St. Louis, Missouri (MO). We assessed the demographic and social characteristics of patients prescribed PrEP and documented their insurance and copayment experiences. We assessed retention in PrEP care at three and six months. Multivariate analyses were used to predict retention in care among men who have sex with men (MSM). HIV acquisition among the cohort was also assessed.ResultsA total of 267 (RI: 117; MS: 88; MO: 62) patients were prescribed PrEP; 81% filled prescriptions (RI: 73%; MS: 82%; MO: 94%; p<0.001). Patients in MS and MO were more commonly African American than in RI (72% and 26% vs. 7%, respectively), but less frequently Latino (2% and 3% vs. 24%, respectively). More patients reported living below the federal poverty line in MS (52%) compared to MO (23%) and RI (26%). Most patients were MSM (RI: 92%; MS: 88%; MO: 84%). The majority of MSM reported recent condomless anal sex (RI: 70%; MS: 65%; MO: 75%). Among 171 patients prescribed PrEP at least six months beforehand, 72% were retained in care at three months (RI: 68%; MS: 70%; MO: 87%; p=0.12) and 57% were retained in PrEP care at six months (RI: 53%: MS: 61%; MO: 63%; p=0.51). Insurance status and medication costs were not found to be significant barriers for obtaining PrEP. Three patients became infected with HIV during the six-month period after being prescribed PrEP (1.1%; 3/267), including one in RI (suspected acute HIV infection), one in MO (confirmed poor adherence) and one in MS (seroconverted just prior to initiation).ConclusionsPrEP initiation and retention in care differed across these distinct settings. In contrast, retention in PrEP care was consistently suboptimal across sites. Further research is needed to identify the individual, social and structural factors that may impede or enhance retention in PrEP care
Highlights
Despite the efficacy of pre-exposure prophylaxis (PrEP) in preventing HIV transmission, few studies have evaluated PrEP use and retention in care outcomes in real-world settings outside of clinical trials
HIV pre-exposure prophylaxis (PrEP) is a biomedical HIV prevention modality that entails the daily use of the singletablet antiretroviral medication emtricitabine (FTC) and tenofovir disoproxil fumarate (TDF) by uninfected individuals at risk for HIV infection
We present demographic and behavioural data for individuals prescribed PrEP, as well as adherence and retention in care outcomes associated with this three-site PrEP implementation programme
Summary
Despite the efficacy of pre-exposure prophylaxis (PrEP) in preventing HIV transmission, few studies have evaluated PrEP use and retention in care outcomes in real-world settings outside of clinical trials. PrEP’s efficacy in preventing HIV acquisition has been demonstrated in randomized controlled trials [1Á5] and open-label studies [6]. These studies demonstrated that better adherence dramatically enhances PrEP’s efficacy [7,8]. A recent study found that PrEP uptake in a primary care setting reached individuals at high risk for HIV acquisition, and no new infections were reported, underscoring both the feasibility of PrEP delivery and its effectiveness in reducing HIV acquisition in real-world clinical settings [11,17]. Evidence is beginning to emerge in some health systems structures in the United States, such as the Kaiser Permanente cohort in Northern California [11], little is known about PrEP implementation in other clinical contexts
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