Medication Adherence in a Nationwide Cohort of Veterans Initiating Pre-exposure Prophylaxis (PrEP) to Prevent HIV Infection

Epps, Puja Van; Maier, Marissa; Lund, Brian C.; Howren, M. Bryant; Beck, Brice; Beste, Lauren A.; Skolnik, Avy A.; Vaughan-Sarrazin, Mary; Ohl, Michael

doi:10.1097/qai.0000000000001598

Cited by 53 publications

(39 citation statements)

References 11 publications

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“…We found that PrEP discontinuations were more likely to occur among persons who were younger, who identified as transgender women, and who had multiple mental health disorders. Our findings corroborates prior studies that have found an association between younger age and challenges accessing or continuing with PrEP [14,30,31] and highlights additional sub-populations, including transgender women and those with mental health disorders, for whom intensive and/or tailored support for continued PrEP use may be beneficial. Because HIV incidence rates among young MSM and transgender women are among the highest in any sub-population nationally [32], and because mental health diagnoses have been associated with HIV risk behaviours [33,34], addressing ineffective PrEP use in these groups should be prioritized.…”

Section: Discussionsupporting

confidence: 90%

“…A retrospective chart review at an academic health system in New York found that retention in PrEP care after six months was 42%. [17] In a national study of over 1000 PrEP users at the Veterans Health Administration, 44% of PrEP users discontinued PrEP within the first year [14], and 38% of PrEP users at a community-based clinic in San Francisco discontinued PrEP by 13 months [13]. Similarly, 26% of nearly 5000 patients who initiated PrEP between 2012 and 2017 at an integrated healthcare organization in Northern California discontinued PrEP [11].…”

Section: Discussionmentioning

confidence: 99%

“…However, discontinuations of PrEP use among individuals with ongoing risks for acquiring HIV could decrease the effectiveness of PrEP [10,11]. Observational studies of PrEP prescribing in healthcare settings have demonstrated that many patients who initiate PrEP subsequently discontinue its use [12][13][14][15]. Within an integrated healthcare system in Northern California, discontinuations of PrEP use have been associated with incident HIV diagnoses [11].…”

Section: Introductionmentioning

confidence: 99%

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Patterns and clinical consequences of discontinuing HIV preexposure prophylaxis during primary care

et al. 2019

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Introduction Discontinuations of HIV preexposure prophylaxis (Pr EP ) by at‐risk individuals could decrease the effectiveness of Pr EP . Our objective was to characterize patterns of, reasons for, and clinical outcomes associated with Pr EP discontinuations in primary care. Methods We conducted medical chart reviews for patients prescribed Pr EP during 2011 to 2014 at a Boston community health centre specializing in healthcare for sexual and gender minorities. Patients were followed through 2015. We characterized patients’ sociodemographics, relationship status, behavioural health conditions, patterns of and reasons for Pr EP discontinuations, and HIV seroconversions. Cox proportional hazards models were used to assess patient factors associated with Pr EP discontinuations. Results Of the 663 patients prescribed Pr EP , the median age was 33 years, 96% were men who have sex with men ( MSM ) and 73% were non‐Hispanic white; 40% were in committed relationships and 15% had HIV ‐infected partners. Patients either used Pr EP continuously (60%), had 1 or more discontinuations (36%), or did not initiate Pr EP (4%). Discontinuations were most often due to a decrease in HIV risk perception (33%), non‐adherence to care plans (16%), or insurance barriers (12%). Of the 7 (1.1%) Pr EP patients diagnosed with HIV , 1 was HIV ‐infected at baseline, 2 seroconverted while using Pr EP , and 4 seroconverted after discontinuations. In a multivariable model adjusted for race/ethnicity, relationship status, substance use disorders, and insurance status, those who were less than 30 years old ( aHR 2.0, 95% CI 1.4 to 2.9 for ages 18 to 24, aHR 2.2, 95% CI 1.6 to 3.1 for ages 25 to 29, vs. ages 30 to 39 years), who identified as transgender women ( aHR 2.0, 95% CI 1.2 to 3.4, vs. cisgender men), and who had mental health disorders ( aHR 1.2, 95% CI 1.1 to 1.4 for each additional disorder) were more likely to have discontinuations. Conclusions Discontinuations of Pr EP use among this American sample of predominately MSM were common, particularly among patients who were younger, identified as transgender women, or had behavioural health issues. As HIV ...

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Patterns and clinical consequences of discontinuing HIV preexposure prophylaxis during primary care

et al. 2019

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“…24 Finally, PrEP discontinuation is common, with one study finding that 44% of initiators discontinued within one year. 25,26 Prescription renewals or repeat pharmacy fills could be used to derive measures of duration of use, such as the mean percentage of days covered by PrEP in a given time period, 25-28 but this aspect of the data has yet to be described.…”

Section: Numerators For Prep Coverage: Measures Of Prep Use and Accessmentioning

confidence: 99%

Progress and pitfalls in measuring HIV preexposure prophylaxis coverage in the United States

Rosenberg

Marcus

2018

Annals of Epidemiology

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Once-daily emtricitabine/tenofovir for HIV preexposure prophylaxis (PrEP) has emerged as a primary tool for HIV prevention. PrEP has been shown to be highly effective in clinical trials 1-5 and demonstration projects, 6,7 and HIV incidence has been low among PrEP users in clinical practice. 8,9 Scale-up of PrEP could substantially reduce HIV incidence at the population level if coverage in high-risk individuals is sufficient. 10 As efforts to scale up PrEP are underway at the local, state, and national levels, 11-15 it is critical to develop rigorous metrics for monitoring success, including measures of PrEP coverage in at-risk populations. In this issue of Annals of Epidemiology, four studies lay the foundation for such metrics. Two studies conduct trend (Sullivan et al. 16) and cross-sectional (Siegler et al. 17) analyses of novel measures of PrEP coverage, specifically the prevalence of PrEP use and the ratio of PrEP users to the number of new HIV diagnoses ("PrEP-to-need ratio"). These studies identify populations with slower increases in PrEP use over time, and with lower levels of PrEP use relative to need, including individuals in the south, women, and those at extremes of age. Siegler et al. evaluate PrEP access using the location of PrEP-providing clinics, finding a lower density of PrEP clinics in the south and in counties with higher proportions of the population living in poverty, uninsured, or of racial/ethnic minority groups. 18 Finally, Smith et al. develop estimates of the number of adults with indications for PrEP by race/ ethnicity, HIV-transmission risk group, and state, suggesting that these estimates could serve as denominators for estimates of PrEP coverage. 19 Taken together, these four studies rise to the challenge of developing metrics for PrEP coverage in the United States, with estimates of PrEP use and access as numerators and estimates of PrEP need as denominators. Here, we discuss what these new metrics do and do not measure, their utility for informing policy, and paths forward for future measure development.

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“…However, few studies have explored the influence of alcohol and drug use specifically in the context of PrEP care. Two studies using medication refill data from large healthcare systems showed that patients with substance use diagnoses had fewer days covered by PrEP [32][33] . However, neither alcohol nor other substance use were associated with PrEP drug levels over time in the iPrEx OLE or DEMO Project 10,11 .…”

Section: Introductionmentioning

confidence: 99%

Vulnerable Periods: Characterizing Patterns of Sexual Risk and Substance Use During Lapses in Adherence to HIV Pre-exposure Prophylaxis Among Men Who Have Sex With Men

Wray

Chan

Kahler

et al. 2019

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Background: Pre-exposure prophylaxis (PrEP) is highly efficacious, but some groups of men who have sex with men (MSM) may have difficulty adhering to daily dosing. Prevention-effective adherence suggests that PrEP's efficacy depends on adherence at the time of HIV exposure, yet few studies have examined how exposures (i.e., high-risk sex) overlap with periods of consecutive missed PrEP doses. Substance use may also play a role in these vulnerable periods. Methods: We used digital pill bottles to monitor the daily adherence of 40 PrEP-experienced patients recruited from an outpatient clinic in the Northeastern US over a six-month period. Participants also completed detailed online diaries every two weeks during this time that surveyed their sexual behavior and substance use each day. Results: Daily adherence was high overall (M = 83.9%, SD = 18.0%), but 53% (N = 21) had a lapse of > 3 consecutive daily PrEP doses over six months. Participants' rate of engaging in highrisk condomless anal sex (CAS) did not differ across lapse days versus continuously-adherent days. Alcohol use was not associated with engaging in CAS during a PrEP lapse. However, participants reported engaging in CAS significantly more often during a PrEP adherence lapse on days when they also used stimulant drugs.

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Medication Adherence in a Nationwide Cohort of Veterans Initiating Pre-exposure Prophylaxis (PrEP) to Prevent HIV Infection

Abstract: First-year adherence with TDF/FTC was overall high in a nationwide cohort of PrEP users. Differences in adherence by age, race, and sex suggest potential for disparities in PrEP effectiveness in routine clinical practice.

Cited by 53 publications

References 11 publications

Patterns and clinical consequences of discontinuing HIV preexposure prophylaxis during primary care

Patterns and clinical consequences of discontinuing HIV preexposure prophylaxis during primary care

Progress and pitfalls in measuring HIV preexposure prophylaxis coverage in the United States

Vulnerable Periods: Characterizing Patterns of Sexual Risk and Substance Use During Lapses in Adherence to HIV Pre-exposure Prophylaxis Among Men Who Have Sex With Men

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