PrEP continuum insufficient in populations at high risk for HIV
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Populations disproportionately impacted by HIV were less likely to be engaged in preexposure prophylaxis, or PrEP, continuum of care, according to findings published in JAMA Network Open.
The high-risk populations included African American individuals, “Latinx” individuals, adults aged 18 to 25 years and individuals with substance use disorders. “Latinx” is used as a gender-neutral alternative to Latino or Latina.
“The main takeaway is that health care access is critical in getting PrEP to individuals who could benefit the most from the regimen,” J. Carlo Hojilla, RN, PhD, a postdoctoral fellow in the Drug Abuse Treatment and Services Research Training Program at the University of California, San Francisco, told Healio Primary Care. “However, the high rate of discontinuation in key demographic and clinical subgroups disproportionately impacted by HIV suggests that health care access alone is not sufficient. We need more effective strategies that are responsive to the needs and barriers of these important populations to keep them engaged in PrEP care.”
The PrEP care continuum includes linkage to care, prescription of PrEP, initiation of PrEP, persistence of care during risk periods and reinitiation of care following discontinuance.
Hojilla and colleagues conducted a retrospective cohort study of 13,906 adults linked to PrEP care in the Kaiser Permanente Northern California network between July 2012 and March 2019. Among the study cohort, 48.7% were white, 95.1% were men and the mean age was 33 years. Data were obtained through electronic health records. The researchers followed participants from the date of linkage to care until March 2019, an HIV diagnosis, discontinuation of health plan with Kaiser Permanente or death; total follow-up was 26,210 person-years.
Participation in PrEP
Among the individuals linked to care during the study period, 88.1% were prescribed PrEP (95% CI, 86.1-89.9), and of these, 98.2% (95% CI, 97.2-98.8) initiated PrEP, according to Hojilla and colleagues.
Following PrEP initiation, 52.2% (95% CI, 48.9-55.7) of participants discontinued PrEP at least once, and 60.2% (95% CI, 52.2-68.3) of them later reinitiated PrEP. Individuals older than 45 years were more likely to be prescribed PrEP compared with individuals aged 18 to 25 years (HR = 1.21; 95% CI, 1.14-1.29). Also, older individuals were more likely to initiate PrEP (HR = 1.09; 95% CI, 1.02-1.16) and less likely to discontinue it (HR = 0.46, 95% CI, 0.42-0.52).
HIV incidence
The researchers reported that HIV incidence was highest among individuals who discontinued PrEP and did not reinitiate it, with 1.28 new infections per 100 person-years. Overall, 0.98% of the study cohort was diagnosed with HIV; this included diagnoses during the PrEP eligibility assessment at the time of linkage to care.
Excluding diagnoses during linkage to care, the overall HIV incidence rate was 0.35 infections per 100 person-years. The rate increased to 0.87 new infections per 100 person-years when accounting for only those who were not prescribed PrEP. The incidence rate further increased to 1.06 new infections per 100 person-years among those who were prescribed PrEP but did not initiate the regimen.
High-risk populations
African American and Latinx individuals were less likely than white individuals to receive a PrEP prescription (African American: HR = 0.74; 95% CI, 0.69-0.81; Latinx: HR = 0.88; 95% CI, 0.84-0.93) and initiate PrEP (African American: HR = 0.87; 95% CI, 0.80-0.95; Latinx: HR = 0.90; 95% CI, 0.86-0.95). Additionally, they were more likely to discontinue PrEP if initiated (African American: HR = 1.36; 95% CI, 1.17-1.57; Latinx: HR = 1.33; 95% CI, 1.22-1.46).
PrEP prescription rates were also lower among women (HR = 0.56; 95% CI, 0.50-0.62), individuals with lower neighborhood-level socioeconomic status (HR = 0.72; 95% CI, 0.68-0.76) and individuals with a substance use disorder (HR = 0.88; 95% CI, 0.82-0.94). These populations were also less likely to initiate PrEP (women: HR = 0.71; 95% CI, 0.64-0.80; lower socioeconomic states: HR = 0.93; 95% CI, 0.87-.0.99; substance use disorder: HR = 0.88; 95% CI, 0.81-0.95) and were more likely to discontinue PrEP if initiated (women: HR = 1.99; 95% CI, 1.67-2.38; lower socioeconomic status: HR = 1.40 95% CI, 1.26-1.57; substance use disorder: HR = 1.23; 95% CI, 1.09-1.39).
While the overall incidence of HIV in the study cohort was low, Hojilla said that more work is needed to examine the effectiveness of strategies like PrEP in the real world.
“A one-size-fits-all approach will not work in addressing the diverse needs of our patients, particularly those who we want to reach the most. What effective targeted interventions look like continues to be a work in progress, but it means that we need to be more in tune to the needs of our patients and the barriers they face,” Hojilla said. “We can do that by offering individuals better choices in how they access PrEP and how they engage with care, and by offering PrEP modalities that work best for them, whether that’s daily PrEP, on-demand PrEP, or hopefully soon, long-acting injectable PrEP. It also means recognizing and addressing HIV and PrEP stigma, discrimination and structural racism — all of which drive health inequities.”
Primary care providers are ideally positioned to address HIV risk with patients, according to Jonathan Volk, MD, study coauthor and an infectious disease specialist at The Permanente Medical Group.
“Offering PrEP to persons at risk for HIV infection is an incredibly powerful intervention that PCPs can use to decrease HIV incidence,” Volk told Healio Primary Care. “In addition, because we know that many individuals may be hesitant to disclose behaviors for fear of being stigmatized, it is also important that PCPs consider PrEP for individuals who request PrEP, regardless of self-reported risk.”