Among patients treated at public health-funded primary care clinics in San Francisco, California, the rates of preexposure prophylaxis (PrEP) discontinuation were high compared with those of research-based and specialty PrEP programs, according to study results published in AIDS. Discrepancies in discontinuation rates include patient age, race/ethnicity, and risk category.
The investigators conducted a study that calculated PrEP discontinuation rates and recorded demographic and risk variables among patients within the San Francisco Department of Public Health Primary Care Clinics. Patients included in the analysis were verified to have had a clinician-provided PrEP prescription, were not receiving postexposure prophylaxis, and were not known to be HIV infected.
Throughout the evaluation period from January 2012 to July 2017, 348 patients received PrEP (84% male at birth). Patient race/ethnicity was diverse and included 39% white, 27% Latinx, and 12% black. Individuals were classified into the following exclusive categories: serodifferent relationship (16%), men who have sex with men (66%), people who inject drugs (~1%), transgender women who have sex with men (13%), and high-risk heterosexual individuals (4.9%).
Approximately 25% of the cohort had at least 1 gap in PrEP use after initiation. The most common reasons for gaps in treatment were lack of follow-up (46%), missed visits or laboratory testing (44%), medication cost (12%), and decreased HIV risk (10%); 16% of gaps did not have documented reasons.
Before discontinuation, the median duration of PrEP was 8.3 months. Study results found that white patients had a longer duration of PrEP use compared with black patients (330 days vs 120 days). Compared with white patients, black patients were the only racial/ethnic group to have a significantly higher risk of discontinuing PrEP use (adjusted hazard ratio [aHR], 1.87). In addition, adjusted analysis revealed that older age was linked to a lower risk of having a gap in PrEP use (aHR per decade of age, 0.89).
Compared with men who have sex with men, PrEP discontinuation was significantly more likely among intravenous drug users (aHR, 4.80) and transgender women having sex with men (aHR, 1.94). Patients who reported a history of drug use were also more likely to discontinue PrEP (aHR, 1.55) compared with patients who did not report any drug use.
“Our analysis demonstrated that clinics with PrEP panel management or patient navigation did not have lower rates of PrEP discontinuations [aHR 1.23],” the authors wrote. Panel management was not consistently implemented within the different clinical settings in the study. “[F]urther research into components of PrEP management that may lead to improved outcomes (eg, outreach to patients who missed appointments or follow-up laboratory testing) is needed. It is also possible that underlying systemic challenges at these clinics (eg, not having integrated laboratory services or not having the ability to make follow-up appointments while in clinic), may also have contributed to the lack of improvement seen.”
“We found that PrEP discontinuation was high among a diverse primary care-based cohort of patients receiving PrEP, with significant disparities among populations disproportionally impacted by HIV,” continued the researchers. “Additional data are needed to understand patient, provider, and structural factors associated with PrEP discontinuation and interventions to support PrEP use for patients at risk for HIV.”
Scott HM, Spinelli M, Vittinghoff E, et al. Racial/ethnic and HIV risk category disparities in PrEP discontinuation among patients in publicly-funded primary care clinics [published online August 20, 2019]. AIDS. doi:10.1097/QAD.0000000000002347