Discontinuation, suboptimal adherence, and reinitiation of oral HIV pre-exposure prophylaxis: a global systematic review and meta-analysis

Zhang, Jing; Li, Chunyan; Xu, Junjie; Hu, Zhili; Rutstein, Sarah E.; Tucker, Joseph D.; Ong, Jason J.; Jiang, Yongjun; Geng, Wenqing; Wright, Sarah Towner; Cohen, Myron S.; Shang, Hong; Tang, Weiming

doi:10.1016/s2352-3018(22)00030-3

Cited by 102 publications

(71 citation statements)

References 81 publications

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“…This large study involved a wide range of clinical and non-clinical stakeholders with varied perspectives and priorities, within a national PrEP programme. We focussed on adherence to PrEP and retention in care which can be problematic steps within the PrEP care cascade at which there are known to be inequity in outcomes for key vulnerable populations [6]. Our innovative approach draws directly on staff and patient perspectives and uses the cumulative knowledge embodied within theories of implementation [29] and contributes to implementation science through the shared language and depiction of core concepts (i.e., intervention functions and behaviour change techniques).…”

Section: Discussionmentioning

confidence: 99%

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Improving HIV pre-exposure prophylaxis (PrEP) adherence and retention in care: Recommendation development from a national PrEP programme

MacDonald

Estcourt

Flowers

et al. 2022

Preprint

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Introduction: HIV pre-exposure prophylaxis (PrEP) is a key component of HIV combination prevention. Effective prevention needs people to adhere to PrEP during periods of risk and remain in care. However, relevant models of care are under-researched. Using data from the first two years of Scotlands PrEP programme, we explored barriers and facilitators to PrEP adherence and retention in care and systematically developed evidence-based, theoretically-informed recommendations to enhance future adherence and retention. Methods: We conducted semi-structured interviews and focus groups (09/2018-07/2019) with geographically and demographically diverse patients who were either using/declined/stopped or had been assessed as ineligible for PrEP (n=39), healthcare professionals involved in PrEP provision (n= 54), non-governmental organisation service users (n=9) and staff (n=15) across Scotland. We used thematic analysis to map key barriers and facilitators to priority areas that could enhance adherence and retention in care. Next, we used analytic tools from implementation science (Theoretical Domains Framework, Intervention Functions, Behaviour Change Technique Taxonomy, APEASE criteria) and expert opinion to systematically generate recommendations to enhance future PrEP adherence and retention in care. Results: Barriers and facilitators to adherence and retention in care were diverse and multi-layered. Barriers included perceived complexity of event-based dosing, the tendency for users to stop PrEP before seeking professional support, troublesome side-effects, limited flexibility in the settings, timings, and nature of appointments for follow up, enduring PrEP-related stigma and emerging stigmas around not using PrEP. Facilitators included flexible appointment scheduling, reminders, and processes to follow up non-attenders. We generated 25 wide-ranging but specific recommendations for key stakeholders, for example, emphasising the benefits of PrEP reviews and providing appointments flexibly within individualised PrEP care; using clinic systems to remind/recall PrEP users for review; supporting PrEP conversations among sexual partners; clear guidance on event-based dosing; encouraging/commitment to good PrEP citizenship; and detailed discussion on managing side-effects and care/coping planning activities. Conclusions: PrEP adherence and retention in care is challenging for many people. Such challenges reduce the benefits of PrEP at individual and population levels. Our findings identify and provide solutions to where and how collaborative interventions across public health, clinical, and community practice could address these challenges.

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Section: Discussionmentioning

confidence: 99%

“…Evidence to date suggests that adherence to PrEP and retention in care is challenging [1, [3][4][5][6]. A systematic review of PrEP trials clearly demonstrated that efficacy is associated with adherence [1].…”

Section: Introductionmentioning

confidence: 99%

Improving HIV pre-exposure prophylaxis (PrEP) adherence and retention in care: Recommendation development from a national PrEP programme

MacDonald

Estcourt

Flowers

et al. 2022

Preprint

View full text Add to dashboard Cite

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“…National data suggest that 87% of patients in the US remain continuously engaged in PrEP care three months after initiation, 73% remain persistent at six months [ 16 ], and about 56% of patients remained continuously engaged in PrEP one year after initiation [ 20 ]. A recent meta-analysis of studies in North America similarly suggests that about 40% of individuals will disengage from PrEP care within 6 months [ 7 ]. Among studies focusing on specific regions or cities of the US, continuous engagement in PrEP care at six months after initiation is shown to range from about 30–40% in Atlanta and North Carolina to 76% in Milwaukee [ 3 , 4 , 7 ].…”

Section: Discussionmentioning

confidence: 99%

Patterns of Pre-exposure Prophylaxis (PrEP) Use in a Population Accessing PrEP in Jackson, Mississippi

et al. 2022

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Pre-exposure prophylaxis (PrEP) persistence is suboptimal in the United States. In the Deep South, a region with high rates of new HIV diagnosis, patterns of PrEP discontinuation remain unexplored. We evaluated data from a clinic-based PrEP program in Jackson, Mississippi and included patients initiating PrEP between August 2018 and April 2021. We considered patients to have a gap in PrEP coverage if they had at least 30 days without an active PrEP prescription; those who restarted PrEP after 30 days were classified as ‘stopped and restarted’ and those who never obtained a new PrEP prescription were classified as ‘stopped and did not restart’. Patients without a gap in coverage were considered ‘continuously on PrEP’. We estimated median time to first PrEP discontinuation and examined factors associated with time to first PrEP discontinuation. Of 171 patients who received an initial 90-day PrEP prescription; 75% were assigned male at birth and 74% identified as Black. The median time to first discontinuation was 90 days (95% CI 90–114). Twenty-two percent were continuously on PrEP, 28% stopped and restarted (median time off PrEP = 102 days), and 50% stopped and did not restart. Associations with early PrEP stoppage were notable for patients assigned sex female vs male (adjusted hazard ratio [aHR] = 1.6, 95% CI 1.0–2.5) and those living over 25 miles from clinic vs. 0–10 miles (aHR 1.89, 95% CI 1.2–3.0). Most patients never refilled an initial PrEP prescription though many patients re-started PrEP. Interventions to improve persistence and facilitate re-starts are needed.

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“…A systematic review of oral pre-exposure prophylaxis (PrEP) discontinuation and suboptimal adherence included 59 longitudinal studies or randomised trials globally (n=43 917). 6 The pooled proportion of PrEP discontinuation within 6 months of initiation was 41% (95% CI 19% to 64%; 32% among gay, bisexual and other men who have sex with men, 43% among cisgender girls and women, 72% among heterosexual men and women, and 62% among people who inject drugs). Pooled suboptimal adherence (fewer doses than required to reach protective drug concentration according to type of sexual exposure and dosing schedule) within 6 months was 38% (95% CI 8% to 67%) and was highest among adults ≤24 years (62%) and in settings with high HIV incidence.…”

Section: Global Systematic Review Shows That Less Than a Third Of Ora...mentioning

confidence: 97%

Section: Global Systematic Review Shows That Less Than a Third Of Ora...mentioning

confidence: 99%

Research news in clinical context

Tan¹,

Daskalopoulou

Thomson-Glover

2022

Sex Transm Infect

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Discontinuation, suboptimal adherence, and reinitiation of oral HIV pre-exposure prophylaxis: a global systematic review and meta-analysis

Cited by 102 publications

References 81 publications

Improving HIV pre-exposure prophylaxis (PrEP) adherence and retention in care: Recommendation development from a national PrEP programme

Improving HIV pre-exposure prophylaxis (PrEP) adherence and retention in care: Recommendation development from a national PrEP programme

Patterns of Pre-exposure Prophylaxis (PrEP) Use in a Population Accessing PrEP in Jackson, Mississippi

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