Missed Doctor's Visits Are a Sign of Future PrEP Discontinuation

Retention of HIV pre-exposure prophylaxis (PrEP) is a challenge among diverse patient populations, and a recent study shows that missed doctor’s visits are associated with future discontinuation of treatment.

The study, published in the journal Open Forum Infectious Diseases, followed 364 individuals who were prescribed PrEP at the San Francisco Primary Care Clinics between July 2012 and August 2017. The study found that 16% discontinued PrEP before 90 days, 46% discontinued later, and 38% remained in treatment over 12 months.

“I think the biggest take-aways for my analysis are that only 38% of individuals remain on PrEP over a 1-year median observation time,” study author Matthew Spinelli, MD, of the University of California San Francisco’s Division of HIV, Infectious Diseases & Global Medicine, told Contagion^®. “I was surprised at how few people persisted on PrEP for more than a few months. Missing or no-showing a visit without cancelling in advance portends a 52% higher risk of stopping PrEP in the future in our adjusted model. Other groups, such as younger PrEP users, had higher risks of stopping, which is concerning given rising HIV incidence in younger US [men who have sex with men (MSM)] for instance.”

Keeping individuals engaged with PrEP in primary care settings is key to PrEP’s role in reducing the incidence of HIV infections. Reasons for discontinuing treatment included cost or insurance issues for 13% of participants; 44% indicated difficulty attending visits or completing tests; 11% perceived they had a lower HIV risk; and 4% reported adverse effects, according to the study.

Missed visits were strongly associated with discontinuation and should be considered a red flag to trigger interventions and consideration of differentiated care, investigators found.

Interventions could include mental health/substance use services, mobile health, and other flexible follow-up strategies, such as phone visits or drop-in availability.

“Possible next steps include providing more flexible clinical care systems such as ‘express PrEP visits’ being implemented in San Francisco and London and telemedicine and home delivery models, which can address some of the hassle factor of attending lab and clinical visits,” Spinelli told Contagion^®. “For those who need additional support but require greater flexibility in their care delivery, drop-in visits, or technology-based support such as two-way messaging through smartphone applications could be helpful.”

Spinelli noted that he is working to develop a urine tenofovir immunoassay for monitoring adherence along with providing feedback to participants.

“Overall, I want health care providers to know that many of the people to whom they prescribe PrEP are struggling with both adherence and persistence on PrEP, and they may require additional support,” Spinelli told Contagion^®. “A missed clinical visit is a warning sign that your patient is struggling to remain on PrEP. I would recommend calling them to express concern and offer to provide support.”

Suboptimal retention in PrEP care has been found in a number of studies, according to a report that discussed an interdisciplinary model including clinical pharmacists. Efforts to increase uptake and adherence to PrEP have included a multimedia campaign called PrEP4Love, and other studies have looked at strategies such as on-demand PrEP dosing for MSM.