Lack of health insurance is associated with delays in PrEP initiation among young black men who have sex with men in Atlanta, US: a longitudinal cohort study

Abstract

Introduction Delays between receiving a PrEP prescription and taking a first dose increase the risk of HIV infection. This is especially relevant in populations with high HIV incidence, such as young black men who have sex with men (YBMSM) in the United States. Additionally, YBMSM have relatively low levels of health insurance. We investigated whether lack of health insurance and reliance on PrEP funding through the manufacturer assistance programme (MAP) leads to delays in initiation of PrEP. Methods HIV‐negative YBMSM were offered PrEP as part of a prospective cohort. Enrolment began in June 2015 with follow‐up through February 2019. Interested participants attended a PrEP clinician visit and received a prescription. Those with health insurance received a copay assistance card; those without insurance accessed PrEP using the MAP. The primary outcome was the days between prescription and initiation. The effect of insurance status on this delay was modelled using a Cox proportional hazards model. Results and Discussion The median delay between receipt of a PrEP prescription and taking a first dose was 12 days (IQR 3 to 32). Compared to uninsured participants, the adjusted hazard ratio for PrEP initiation for those with insurance was 2.72 (95% CI 1.82 to 4.06). The adjusted median time to initiation for insured participants was 5 days versus 21 days for those without insurance (p < 0.0001). Older age and STI diagnosis were also associated with faster PrEP initiation. Despite equivalent access to PrEP provided by the study, YBMSM without insurance had longer delays in initiation after receipt of a prescription. Overall, the observed delay in PrEP initiation increases the chances of HIV infection and the possibility of PrEP initiation after undetected seroconversion. Conclusions The extended time period between PrEP prescription and taking a first dose increases the risk of HIV transmission. Younger YBMSM and those without health insurance had longer delays in PrEP initiation. Immediate PrEP initiation programmes could decrease the likelihood of this occurrence and mitigate the disparity in initiation between those with and without health insurance. Clinical Trial Number: NCT02503618.

Regional Disparities in Qualified Health Plans’ Prior Authorization Requirements for HIV Pre-exposure Prophylaxis in the United States

“…One research group in the South has demonstrated a delay in PrEP initiation for people who relied on drug manufacturer assistance programs, which require application paperwork similar to insurance companies' prior authorizations. 46 Although some states have laws stating that an insurance company must respond to a medication prior authorization request within 2 days, some states give insurers up to 10 days, and many states have no regulation on response time. 47 If this period only includes business days, it could result in additional delays because of weekends and holidays.…”

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

“…Four of these studies examined PrEP initiation based on depressive symptoms and found no relationship. In a longitudinal analysis of 154 Black MSM in Atlanta, GA, depression was not associated with a delay between receiving a PrEP prescription and initiating PrEP [ 53 ]. Similarly, in a prospective observational cohort study with 298 non-Hispanic Black cisgender MSM in Atlanta, GA, depressive symptoms were not associated with PrEP uptake as defined by the date of taking the first PrEP dose after prescription [ 54 ].…”

Preexposure Prophylaxis for Prevention of HIV Acquisition Among Adolescents: Clinical Considerations, 2020

“…The U.S. Public Health Service 2017 guidelines recommend that persons starting PrEP should initiate the medication within 7 days of a negative HIV test (1). However, barriers to obtaining PrEP, such as lack of insurance coverage, can delay initiation and might also adversely affect adherence and persistence for those who have started PrEP (69). Providers and clinical support staff can help adolescents prescribed PrEP by screening for barriers and providing pertinent guidance and support.…”