PrEP Uptake Low Among Young Black MSM

By Anne Harding

September 23, 2019

NEW YORK (Reuters Health) - Uptake of HIV pre-exposure prophylaxis (PrEP) among young black men who have sex with men (YBMSM) is poor and discontinuations are common, new findings in show.

"It might take multiple offers of PrEP over multiple points of contact before people decide they want to initiate," Dr. David Serota of the University of Miami Miller School of Medicine told Reuters Health by email. "This was especially true in the key population that participated in the study."

Dr. Serota, who worked on the study while at Emory University School of Medicine in Atlanta, added, "Although PrEP works extremely well, there is a significant implementation gap. Furthermore, there is a disparity in the distribution of PrEP across the population, where key populations with high HIV incidence tend to have the lowest use of PrEP."

PrEP initiation and persistence is low among YBMSM, Dr. Serota and his team note in Clinical Infectious Diseases, online September 10. To investigate factors associated with PrEP uptake and discontinuation, they looked at 298 HIV-negative men participating in EleMENt, a study of substance use, HIV and sexually transmitted infections (STI) among YBMSM living in Atlanta.

Just over three-quarters of study participants reported having anal sex without condoms in the previous six months, while 42% either had an STI in the past year or were diagnosed with a bacterial STI at baseline.

Men participating in the study were offered PrEP at every study visit, and could start treatment whether or not they met Centers for Disease Control and Prevention (CDC) guidelines. Nearly every patient received PrEP for free through insurance or the manufacturer assistance program, and investigators contacted study participants after they visited a clinician to receive PrEP to make sure they had obtained the medications.

During 440 person-years of follow-up, 44% of the 279 patients not taking PrEP at baseline initiated PrEP. Among men who started PrEP, 69% stopped, 40% of whom did not start the treatment again.

Reasons for discontinuation were available for 34 patients, with the most frequent being low perceived risk, cited by 31%; problems attending visits or picking up medications, 13%; and side effects, 10%.

Twenty-three incident HIV infections occurred among study participants (5.23/100 person-years). Incidence was significantly lower for men on PrEP, at 3.15/100 person-years, versus 8.90/100 person-years for those who never used PrEP (incidence rate ratio, 0.39).

Men started PrEP a median of 122 days after their baseline visit, while one-quarter started PrEP more than nine months later. Factors associated with increased PrEP uptake included higher self-efficacy for problem solving, STI diagnosis and condomless anal intercourse (CAI).

Patients who started PrEP and then stopped during the study discontinued treatment at a median of 159 days after their first dose.

Younger patients, cannabis users and those diagnosed with STI stopped PrEP earlier, while having fewer sex partners was also associated with earlier PrEP discontinuation. Final PrEP discontinuation occurred at a median of 223 days, and was also associated with younger age, cannabis use and fewer sex partners, but not STIs.

Thirty-one percent of the study participants reported being on PrEP at their last study visit.

"Based on the high HIV incidence observed in our study PrEP uptake was suboptimal," Dr. Serota said. "Three steps to increase uptake include improving outreach/access, novel delivery methods of PrEP, and alternative dosing formulations of PrEP."

Some promising approaches to lowering barriers include using "PrEP Navigator" to guide patients through the process of initiating treatment and offering treatment via telemedicine, mobile outreach clinics, minute clinics, and retail pharmacies, the researcher added.

"Finally, 'on-demand' PrEP has been shown effective in European studies, but has not been studied in the United States," Dr. Serota said. "For people with more infrequent sexual activity or side effects, this approach decreases pill burden, cost, and possibly more tolerable. Tenofovir alafenamide and injectable and implantable PrEP formulations are also under study and will be good to give people an array of delivery options."


Clin Infect Dis 2019.