Patients aged 18 to 25 years; those who are women, Black, Hispanic/Latino, and those with lower socioeconomic status or a history of substance use disorder were found to be at an increased risk for both HIV infection and experiencing gaps in the HIV pre-exposure prophylaxis (PrEP) care continuum, according results of a study published in JAMA Network Open.
Researchers conducted a retrospective cohort study using data obtained from electronic health records to identify patients aged 18 years and older who received PrEP care in Northern California between July 2012 and March 2019. The researchers sought to identity the factors associated with gaps in the HIV PrEP care continuum, as well as patients at increased risk for early PrEP discontinuation. Patients were contacted from the start of their PrEP referral or PrEP-coded clinical encounter (linkage) to either March 2019, diagnosis of HIV infection, discontinuation of health plan membership, or death. The primary outcomes were attrition at each step of the PrEP care continuum and incident HIV infection.
The researchers found that of 13,906 patients included in the study, the median age was 33 (interquartile range [IQR], 27-43) years, 6771 (48.7%) were white, and 13,227 (95.1%) were men. In addition, the total follow-up was 26,210 persons-years (median, 1.6; IQR, 0.7-2.9 years). Of patients who were referred to PrEP care, 88.1% (95% CI, 86.1%-89.9%) were prescribed PrEP; of whom, 98.2% (95% CI, 97.2%-98.8%) initiated treatment. Following initiation of PrEP, 52.2% (95% CI, 48.9%-55.7) of patients discontinued treatment at least once during the study, with subsequent PrEP re-initiation noted among 60.2% (95% CI, 52.2%-68.3%) of those patients.
Compared with patients aged 18 to 25 years, patients older than 45 years had an increased likelihood of receiving a prescription for PrEP (hazard ratio [HR], 1.21; 95% CI, 1.14-1.29), initiating PrEP (HR, 1.09; 95% CI, 1.02-1.16), and discontinuing PrEP (HR, 0.46; 95% CI 0.42-0.52). Data also showed that compared with patients who were White, those who were Black or Hispanic/Latino were less likely to receive a prescription for or initiate PrEP (Black: HR, 0.74; 95% CI, 0.69-0.81]; Hispanic/Latino: HR, 0.88; 95% CI, 0.84-0.93). In addition, patients who were Black or Hispanic/Latino were more likely to discontinue PrEP (HR, 1.36; 95% CI, 1.17-1.57vs HR, 1.33; 95% CI, 1.22-1.46, respectively). Similar results were observed among patients who were women, those with lower socioeconomic status, and those with a SUD.
The limitations of the study included its reliance on pharmacy records which did not directly assess PrEP adherence, the number of patients lost to follow-up due to incident HIV infection, and its predominantly male patient population. The researchers noted that the generalizability of the results may be limited among patients who are women, transgender, or those who are uninsured.
“These findings suggest that health care access alone is not sufficient to optimize PrEP delivery [or] to achieve national HIV prevention goals, including population impact and equity,” additionally, “comprehensive strategies tailored toward high-priority populations are needed to mitigate attrition along the PrEP continuum of care,” the researchers concluded.
Hojilla JC, Hurley LB, Marcus JL, et al. Characterization of HIV preexposure prophylaxis use behaviors and HIV incidence among US adults in an integrated health care system. JAMA Netw Open. Published online August 26, 2021. doi:10.1001/jamanetworkopen.2021.22692