Racial/Ethnic and HIV Risk Category Disparities in Preexposure Prophylaxis Discontinuation Among Patients in Publicly Funded Primary Care Clinics

Hyman M. Scott; Matthew Spinelli; Eric Vittinghoff; Alicia Morehead-Gee; Anne Hirozawa; Catherine James; Hali Hammer; Albert Liu; Monica Gandhi; Susan Buchbinder

Disclosures

AIDS. 2019;33(14):2189-2195. 

In This Article

Abstract and Introduction

Abstract

Objective: Dissemination of preexposure prophylaxis (PrEP) is a priority for reducing new HIV infections, especially among vulnerable populations. However, there are limited data available on PrEP discontinuation following initiation, an important component of the PrEP cascade.

Design: Patients receiving PrEP within the San Francisco Department of Public Health Primary Care Clinics (SFPCC) are included in a PrEP registry if they received a PrEP prescription, were not receiving postexposure prophylaxis, and not known to be HIV-positive.

Methods: We calculated PrEP discontinuation for patients initiating PrEP at any time from January 2012 to July 2017 and evaluated their association with demographic and risk variables using Cox regression analysis.

Results: Overall, 348 patients received PrEP over the evaluation period. The majority (84%) were men, and the cohort was racially/ethnically diverse. The median duration of PrEP use was 8.3 months. In adjusted analysis, PrEP discontinuation was lower among older patients (aHR 0.89; 95% CI 0.80–0.99; P = 0.03); but higher among black patients (compared with white patients; aHR 1.87; 95% CI 1.27–2.74; P = 0.001), patients who inject drugs (aHR 4.80; 95% CI 2.66–8.67; P < 0.001), and transgender women who have sex with men (compared with MSM; aHR 1.94; 95% CI 1.36–2.77; P < 0.001).

Conclusion: Age, racial/ethnic, and risk category disparities in PrEP discontinuation were identified among patients in a public health-funded primary care setting. Further efforts are needed to understand and address PrEP discontinuation among priority populations to maximize the preventive impact of PrEP, and reverse HIV-related disparities at a population level.

Introduction

Preexposure prophylaxis has been shown to have high efficacy in HIV prevention in several clinical trials and clinical cohorts.[1–7] In the United States, although PrEP uptake is increasing each year, uptake has been lower among black and Latino patients than white patients in demonstration projects, clinical cohorts, and national reviews of pharmacy records.[7–11] Similar disparities in adherence rates and PrEP discontinuation were observed in the United States PrEP Demo project.[12]

Continued PrEP use over time is an important step in the PrEP continuum, but there are limited data about PrEP discontinuation rates, particularly within primary care settings with diverse patient populations. In a Kaiser study of 972 patients who initiated PrEP, approximately 30% discontinued PrEP during the 3-year study follow-up period.[13] In this clinical cohort, the risk of discontinuation was the highest among women and those with a history of alcohol use. Similar discontinuation rates were noted in another clinical cohort of PrEP users within a San Francisco sexual health clinic.[14] In an LGBT-focused health center in Chicago, only 43% were still in care after 12 months, with uninsured patients less likely retained in care.[15] However, these cohorts were in clinical settings focused on PrEP, and not necessarily reflective of patients in general primary care practice. Furthermore, both cohorts were nearly all men and approximately 70% white, not reflecting the racial/ethnic demographics of new HIV diagnoses in the United States.[16] As PrEP dissemination expands, more data are needed on implementation within primary care settings with diverse patient populations.[17,18]

In this study, we assessed PrEP discontinuation rates among individuals who initiated PrEP within the San Francisco Department of Public Health Primary Care Clinics (SFPCC), an integrated safety-net primary care network that provides care for uninsured and publically insured patients within San Francisco. We evaluated PrEP use and factors associated with PrEP discontinuation among patients who initiated PrEP from 2012 to 2017.

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