Retention in care outcomes for HIV pre‐exposure prophylaxis implementation programmes among men who have sex with men in three US cities

Abstract

IntroductionDespite the efficacy of pre-exposure prophylaxis (PrEP) in preventing HIV transmission, few studies have evaluated PrEP use and retention in care outcomes in real-world settings outside of clinical trials.MethodsData were collected from PrEP clinical care programmes in three mid-size US cities: Providence, Rhode Island (RI); Jackson, Mississippi (MS); and St. Louis, Missouri (MO). We assessed the demographic and social characteristics of patients prescribed PrEP and documented their insurance and copayment experiences. We assessed retention in PrEP care at three and six months. Multivariate analyses were used to predict retention in care among men who have sex with men (MSM). HIV acquisition among the cohort was also assessed.ResultsA total of 267 (RI: 117; MS: 88; MO: 62) patients were prescribed PrEP; 81% filled prescriptions (RI: 73%; MS: 82%; MO: 94%; p<0.001). Patients in MS and MO were more commonly African American than in RI (72% and 26% vs. 7%, respectively), but less frequently Latino (2% and 3% vs. 24%, respectively). More patients reported living below the federal poverty line in MS (52%) compared to MO (23%) and RI (26%). Most patients were MSM (RI: 92%; MS: 88%; MO: 84%). The majority of MSM reported recent condomless anal sex (RI: 70%; MS: 65%; MO: 75%). Among 171 patients prescribed PrEP at least six months beforehand, 72% were retained in care at three months (RI: 68%; MS: 70%; MO: 87%; p=0.12) and 57% were retained in PrEP care at six months (RI: 53%: MS: 61%; MO: 63%; p=0.51). Insurance status and medication costs were not found to be significant barriers for obtaining PrEP. Three patients became infected with HIV during the six-month period after being prescribed PrEP (1.1%; 3/267), including one in RI (suspected acute HIV infection), one in MO (confirmed poor adherence) and one in MS (seroconverted just prior to initiation).ConclusionsPrEP initiation and retention in care differed across these distinct settings. In contrast, retention in PrEP care was consistently suboptimal across sites. Further research is needed to identify the individual, social and structural factors that may impede or enhance retention in PrEP care

Time to Make the Jump: Translating HIV Pre-exposure Prophylaxis Research Into Real-World Public Health Impact

“…In a three site study in real-world clinical settings, 57% (98/171) of patients were retained in PrEP care at six months. 3 These findings were consistent across three diverse clinical settings in Jackson, Mississippi (61%; 37/61); Providence, Rhode Island (53%; 42/80); and Saint Louis, Missouri (63%; 19/30, p =0.51). However, our higher rates of retention in care reflect our efforts to integrate PrEP into clinical infrastructure rather than stand-alone research studies or demonstration projects.…”

“…8 Furthermore, patients who remained in PrEP care had initially reported risk behaviors or being members of sexual networks that might place them at high risk for HIV acquisition; 89% of our patients were MSM and 69% reported condomless anal sex at least once in the last three months. 3 However, less is understood about the risk behaviors of patients who are not retained in care; it is conceivable that some individuals who are not retained may no longer need PrEP, and therefore discontinue PrEP care. On the other hand, it is conceivable that patients lost to follow-up are the most vulnerable and are at highest risk for HIV acquisition.…”

Implementation of Preexposure Prophylaxis for Human Immunodeficiency Virus Prevention Among Men Who Have Sex With Men at a New England Sexually Transmitted Diseases Clinic

“…The study evaluated PrEP initiation defined as receiving a prescription; subsequent retention in care and adherence were beyond the scope of this analysis but are reported elsewhere. 31,32 Additionally, patients may have sought PrEP care elsewhere after the PrEP education session, which we were not able to measure or incorporate in our analysis. On the level of clinic operations, we lost a significant number of PrEP candidates during the follow-up period.…”

Pre-exposure prophylaxis for MSM and transgender persons in early adopting countries

“…One study of PrEP utilization in clinics in 3 mid-sized U.S. cities found that retention in PrEP care was suboptimal, with only 57% of patients retained in PrEP care at 6 months after initiation. Among those patients retained in care at 6 months, the proportion of patients with optimal adherence for the prior month ranged from 33 to 77%, suggesting a need for interventions to support adherence in real-world clinical settings [70]. …”