Missed Visits Associated With Future Preexposure Prophylaxis (PrEP) Discontinuation Among PrEP Users in a Municipal Primary Care Health Network

Abstract

Background Maintaining retention in preexposure prophylaxis (PrEP) care among diverse patient populations will be needed to support PrEP’s efficacy. We characterized patterns of PrEP care retention in a US municipal primary care health network and examined whether missed visits, a metric of care retention that is easy to evaluate in clinic, are associated with subsequent discontinuation. Methods We included individuals on PrEP from July 2012 until August 2017 in the San Francisco Primary Care Clinics, a 15-clinic municipal health network. We categorized PrEP usage patterns as follows: early discontinuation (<90 days), later discontinuation (after ≥90 days), and continuing use at the end of follow-up. We first examined early discontinuation using adjusted Poisson regression. In patients who continued PrEP for ≥90 days, we examined factors associated with late discontinuation. Results Of the 364 individuals who started PrEP, 16% discontinued PrEP before 90 days, 46% discontinued later, and 38% were retained in care over a median 12 months of observation. Transgender women were more likely to discontinue PrEP early (adjusted risk ratio; 2.16; 95% confidence interval, 1.36–3.49), and younger users were more likely to discontinue late (0.82 per 10-year increase in age; .70–.96), as were persons who use illicit drugs (1.59; 1.02–2.47). Missed visits during use of PrEP were associated with future discontinuation (adjusted risk ratio, 1.52; 95% confidence interval, 1.14–2.03). Later year of current PrEP use was associated with both early and late discontinuation. Conclusion Diverse populations may require differentiated care to continue PrEP. Missed visits should trigger tailored interventions to maximize the impact of PrEP.

Youth‐friendly services and a mobile phone application to promote adherence to pre‐exposure prophylaxis among adolescent men who have sex with men and transgender women at‐risk for HIV in Thailand: a randomized control trial

“…Among the 714 who have cumulatively initiated PrEP nationwide, only 22% continue to take PrEP since 2016 [22]. These uptake and retention challenges are similar to those seen with previous adolescent trials network (ATN) studies in adolescents aged 15 to 19 years, with PrEP discontinuation during ongoing HIV acquisition risk more likely (0.82 per 10‐year increase in age) in younger individuals [23,24].…”

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

“…Person‐time was censored during periods in which participants were disenrolled. Discontinuations/gaps were defined as 90 days without PrEP [9]. HIV seroconversions were ascertained using the SFDPH/CDC’s enhanced HIV surveillance system (eHARS), permitting collection of HIV diagnoses that occurred both within and outside of the SFDPH’s surveillance jurisdiction through mandated HIV diagnosis reporting.…”

“…Pre‐exposure prophylaxis (PrEP) is a highly effective biomedical prevention strategy when taken during periods of HIV risk [1,2]. Although PrEP persistence (sustained PrEP use over time) was high among PrEP users in clinical trials and early demonstration projects [2‐4], it has been variable among later PrEP adopters and in real‐world evaluations, with 15 to 62% of users discontinuing PrEP by six months [5‐14]. Prevention‐effective adherence is a concept which describes the importance of using PrEP during periods of HIV risk, as compared to antiretroviral therapy, for which lifelong adherence is required [15].…”

“A Good Habit”: Telehealth PrEP Users Find Benefit in Quarterly Monitoring Requirements

“…[11][12][13][14][15] Indeed, a recent study conducted in San Francisco, a location with robust PrEP care, found that the most common reason for discontinuation was difficulty attending clinic visits or completing laboratory tests. 16 Technological innovations in PrEP delivery systems may help address structural and social challenges related to PrEP uptake and continuity, such as fear of discrimination on the basis of one's sexual identity, difficulty attending clinic visits, or completing laboratory testing. A recent review of advances in telehealth and PrEP care in the United States outlined 5 unique provider-to-patient delivery models.…”