Access to Care is Key to PrEP Initiation, But More Is Needed to Mitigate Attrition

An analysis of HIV pre-exposure prophylaxis among adults in an integrated health care system found high rates of initiation but gaps in the continuum of care that disproportionately affected vulnerable populations, including minorities and people with substance use disorders.

The retrospective cohort study, published in JAMA Network Open, included 13,906 participants ages 18 and older who received PrEP care between July 2012 and March 2019, according to Kaiser Permanente Northern California electronic health records.

Primary outcomes were attrition at various steps in the process and incidence of HIV infection during 26,210 person-years of follow-up.

“The main takeaway is that healthcare access is critical in getting PrEP to individuals who could benefit the most from the regimen. However, the high rate of discontinuation in key demographic and clinical subgroups disproportionately impacted by HIV suggests that this is not enough,” lead author J. Carlo Hojilla, RN, PhD, a postdoctoral research fellow in the Drug Abuse Treatment and Services Research Training Program at the University of California San Francisco (UCSF), and at the Kaiser Permanente Northern California Division of Research, told Contagion. “We need more effective strategies that are responsive to the needs and barriers of these important populations to keep them engaged in PrEP care.”

Among the participants, median age was 33, 48.7% were White and 95.1% were men. The study found that most of the 88.1% of participants linked to PrEP initiated care (98.2%), and 52.2% discontinued PrEP at least once during the study period. Among those who discontinued PrEP, 60.2% reinstated.

“It was really encouraging to see that a vast majority of the individuals who were linked to PrEP care started PrEP, and that we saw no new HIV infections among those who remained persistent on PrEP,” Hojilla said. “But we know from other studies that individuals from minoritized communities face multiple individual-, social-, and structural-level barriers to PrEP access and persistence. While the disparities we observed were not entirely surprising, they highlight an area of unaddressed need, even in an insured population.”

African American, Latinx, young adults ages 18 to 25 and participants with substance use disorders were found to be particularly vulnerable to gaps in PrEP care.

Participants older than 45 were 1.21 times more likely to receive PrEP prescriptions and 1.09 times more likely to initiate PrEP than those ages 18 to 25. They also were less likely to discontinue PrEP (hazard ratio, 0.46 [95% confidence interval, 0.42-0.52]).

African American and Latinx participants were less likely to receive a PrEP prescription, with hazard ratios of 0.74 and 0.88 respectively, less likely to initiate PrEP (HR, 0.87 and 0.90) and more likely to discontinue PrEP (HR, 1.36 and 1.33).

The study also found that women, participants with low socioeconomic status and those with substance use disorders also were less likely to be prescribed PrEP (HR, 0.56, 0.72, 0.88 respectively) and more likely to discontinue treatment (HR, 1.99, 1.40 and 1.23).

“PrEP has dramatically changed the HIV prevention landscape and we now have the tools necessary to end the HIV epidemic,” Hojilla said. “But to achieve national HIV prevention goals, we need to keep health equity in mind and as we broaden efforts to roll-out PrEP, it will be important to recognize and address the barriers that key populations face to ensure that we maximize the public health impact of PrEP.”

During the study period, 136 participants were diagnosed with HIV, including 45 (33.1%) who were diagnosed during assessment for PrEP eligibility. Excluding those, the overall HIV incidence rate was 0.35 (95%CI, 0.28-0.43) new infections per 100 person-years. HIV incidence was highest among those who discontinued and did not reinitiate PrEP at 1.28 (95% CI, 0.93-1.76) new infections per 100 person-years. No new infections were found among those who remained persistent on PrEP during 9139 person-years of follow-up.

“This work has provided us with important insights on where in the PrEP continuum individuals are falling out of care, which groups of individuals may need additional support, and what the health consequences are of attrition in the PrEP continuum,” Hojilla said. “Our next step is to use these data to develop strategies that will more effectively support individuals on PrEP and address gaps in care.”

Global use of HIV PrEP rose by 69% in 2019, compared with 2018, according to a recent study that examined the association between adoption of World Health Organization guidelines recommending oral PrEP to anyone at substantial risk of HIV and the number of PrEP users.

The US Centers for Disease Control and Prevention estimates that 1.1 million Americans could benefit from PrEP. Efforts are ongoing to address barriers to access and increase uptake and adherence, with strategies under consideration including lowering the threshold to start PrEP and de-medicalizing PrEP by allowing lay providers to play a larger role in delivery.