PrEP Use Varies Significantly Across VHA Facilities

Man holding a pill.
Man holding a pill.
Pre-exposure prophylaxis initiation rates in Veteran's Health Administration facilities were positively associated with certain patient characteristics.

Pre-exposure prophylaxis (PrEP) initiation rates in the Veteran’s Health Administration (VHA) facilities were positively associated with percentage of individuals younger than age 45 years, urban dwellers, tertiary care status, and location, according to a study published in AIDS and Behavior.1

As it is the largest healthcare provider in the United States, with 6 million individuals in care across 140 facilities in 20162 and PrEP made available at a low copay of $11 per month, researchers in this study decided to use the VHA as the health system to identify healthcare facility characteristics associated with higher rates of PrEP use.1

The national mean PrEP initiation rate was 20.0 recipients/100,000 (SD, 22.8). Based on the rate of PrEP initiation, the 140 primary VHA healthcare facilities were grouped into 4 quartiles. The lowest quartile (quartile 1) had a mean PrEP initiation rate of 3.0/100,000 (SD, 2.0), whereas the highest quartile (quartile 4) had a mean PrEP initiation rate of 48.1/100,000 (SD, 29.1). Quartile 2 (medium-low quartile) had a mean PrEP initiation rate of 9.6/100,000 (SD, 2.1), and quartile 3 (medium-high quartile) had a mean PrEP initiation rate of 18.0/100,000 (SD, 2.9). Of the 1600 individuals initiating PrEP between July 1, 2012, and June 30, 3017, 1110 were in quartile 4, 319 were in quartile 3, 133 in quartile 2, and 38 in quartile 1.

In multiple regression analysis, the highest-prescribing facilities were more likely to have a greater proportion of younger, urban-dwelling individuals (β=142.7 [2-tailed P =.018] and β=18.3 [2-tailed P =.038, respectively]); be classified as tertiary care facilities (β=12.2; 2-tailed P=.001); and be located in the West Coast, Hawaii, or Alaska (β=22.1; 2-tailed P <.0001). The proportion of African-Americans in care within a facility was not associated with PrEP initiation (β = 8.3; 2-tailed P =.599).

Researchers noted that “a 16-fold variation in PrEP initiation between the lowest and highest quartiles was greater than would be expected based on socio-demographic factors alone.” Provider expertise and rurality of the patient populations were key predictors of PrEP initiation.

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Because a significant majority of PrEP recipients were men (97%), findings could not be generalized to women. Moreover, interpretation of patterns was less reliable in the lowest quartile because of the small number of PrEP recipients. Researchers were also unable to ascertain patient-level risk behaviors (such as injection drug use and unprotected sex).

Implementation strategies should be sensitive to the PrEP prescribing environment, especially smaller facilities; support noninfectious disease physicians; expand the role for clinical pharmacists and advanced practice clinicians; and leverage the use of telehealth. “Efforts such as these can help ensure equitable access to PrEP across all regions and prescribing environments across health systems,” concluded the researchers.


  1. Maier MM, Gylys-Colwell, Lowy E, et al. Health care facility characteristics are associated with variation in human immunodeficiency virus pre-exposure prophylaxis initiation in Veteran’s Health Administration [published online December 13, 2018]. AIDS Behav. doi: 10.1007/s10461-018-2360-62.  
  2. National Center for Veterans Analysis and Statistics. US Department of Veterans Affairs. VA utilization profile FY 2016. Published November 2017. Accessed January 28, 2019.