Missed opportunities to prevent HIV infections among pre‐exposure prophylaxis users: a population‐based mixed methods study, San Francisco, United States

Abstract

Introduction Pre‐exposure prophylaxis (PrEP) is highly effective, although PrEP adherence and persistence has been variable during real world implementation. Little is known about missed opportunities to enhance PrEP adherence among individuals who later HIV seroconverted after using PrEP. The goal of this analysis was to identify all HIV infections among individuals who had accessed PrEP in an integrated health system in San Francisco, and to identify potentially intervenable factors that could have prevented HIV infection through in‐depth interviews with people who HIV seroconverted after using PrEP. Methods We identified individuals who initiated PrEP in an integrated safety‐net public health system and performed in‐depth chart review to determine person‐time on and after stopping PrEP over six years. We identified all PrEP seroconversions using the Centers for Disease Control and Prevention’s Enhanced HIV/AIDS Reporting System and then calculated HIV incidence while using PrEP and during gaps in use. We then performed in‐depth interviews with those who seroconverted. Results Overall, 986 initiated PrEP across the San Francisco Department of Public Health from July 2012 to November 2018. Data were gathered from 895 person‐years on PrEP and 953 after stopping PrEP. The HIV incidence was 7.5‐fold higher after stopping PrEP compared to while on PrEP (95% CI 1 to 336). Of the eight individuals who HIV seroconverted; only one was taking PrEP at the time of seroconversion but was using on‐demand PrEP inconsistently. All eight agreed to qualitative interviews. Major barriers to PrEP persistence included substance use, mental health and housing loss; difficulty accessing PrEP due to cost, insurance, and the cost and time of medical visits; difficulty weighing PrEP’s benefit versus self‐perceived risk; and entering a primary partnership. The individual who developed HIV using on‐demand PrEP reported confusion about the dosing regimen and which sexual encounters required accompanying PrEP dosing. Conclusions HIV incidence during gaps in PrEP use was nearly eight‐fold higher than while on PrEP in this large cohort in San Francisco. Many individuals who stop PrEP remain at risk of HIV, and participants reported that proactive outreach could potentially have prevented HIV infections. Individuals using non‐daily PrEP may require additional education and support in the United States.

Inconsistent HIV pre‐exposure prophylaxis use and HIV transmission in men who have sex with men (MSM)

“…We read with interest Spinelli et al 's study identifying risk factors for HIV acquisition in patients who use HIV Pre-exposure prophylaxis (PrEP) inconsistently [1]. We concur with these findings and have found some similar associations with inconsistent PREP use in our small cohort of patients in Western Sydney.…”

A Scoping Review Investigating Relationships between Depression, Anxiety, and the PrEP Care Continuum in the United States

“…In a study conducted in San Francisco, CA, one participant identified that depression was a barrier to PrEP adherence, noting the link between depression and substance use as a particular challenge. [ 70 ]. Another study conducted in San Francisco with 25 PrEP users found that mental health problems were associated with adherence difficulties, although participants did not indicate what specific symptoms they experienced [ 50 ].…”

The importance of PrEP persistence in preventing HIV infections on PrEP

“…We agree that stigma related to PrEP or sexual behaviour [2‐4] is an important factor that may interfere with PrEP persistence (consistent use of PrEP during periods with potential HIV exposure) [5]. Participants in this analysis did not report stigma related to being a man who has sex with men (MSM) as a factor in their PrEP gaps, but two participants discussed stigma related to the image of PrEP as a medication for people with multiple sexual partners, and at least one participant feared disclosure of her PrEP use to her partner as she felt it might imply she had outside partners [6].…”