The Persistence of PrEP: Essential for Ending HIV BY MILENA MURRAY, PHARMD, MSC, BCIDP, AAHIVP
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pproximately 30 years after the beginning of the HIV epidemic, emtricitabine–tenofovir disoproxil fumarate (FTC/TDF; Truvada, Gilead) was approved in 2012 as the first preexposure prophylaxis (PrEP) therapy. However, of the 1.2 million Americans eligible for PrEP, only an estimated 70,000 had an active prescription for PrEP as of the end of 2017.1 In 2019, FTC–tenofovir alafenamide (FTC/ TAF; Descovy, Gilead) was approved as a second PrEP therapy option. The PrEP continuum of care includes awareness of risk, uptake of therapy, and adherence and retention in care.2 Barriers to adherence and retention in care include forgetfulness, competing priorities, safety concerns, stigma, and lack of a supportive social network.3 It is well known that PrEP adherence is directly related to efficacy.4 Thus, a barrier that should be addressed is the ability to remain on PrEP after initiation, referred to as PrEP persistence. PrEP persistence is also defined as the length of time a person continues to refill PrEP prescriptions without an interruption of more than 30 days.5 Initiation of PrEP may be a poor measure because the discontinuation of PrEP at 1 month is reported to be as high as 45%.6 A study of 11,807 people with commercial insurance and 647 with Medicaid revealed a significant disparity in PrEP persistence.5 People with commercial insurance remained on PrEP for a median of 13.7 months (95% CI, 13.3-14.1 months) compared with 6.8 months (95% CI, 6.1-7.6 months) among those on Medicaid. After adjustment for covariates, female sex (hazard ratio [HR], 1.81; 95% CI, 1.6-2.1) and younger age (1824 years: HR, 2.4; 95% CI, 2.1-2.7) were predictors of nonpersistence.5
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A separate study of 300 people also showed that age affected PrEP persistence.7 In this study, 85% of participants had at least 1 behavior associated with a high risk for HIV acquisition. Of the participants, 178 (59%) were 30 years of age or older, 287 (96%) were men, and 178 (59%) identified as men who have sex with men (MSM).7 There were 57 (19%) participants who were not white. After 12 months, 44% of participants were persistent with PrEP. Only 34% attended quarterly follow-up visits. Being age 30 years or older was associated positively with PrEP persistence (odds ratio [OR], 1.04; 95% CI, 1.0-1.1). Additionally, a negative association was found with PrEP persistence and minority group status (OR, 0.33; 95% CI, 0.12-0.83).7
Understanding Changes Use Some people may stop PrEP for appropriate reasons, such as no longer being at high risk for HIV acquisition, but many discontinue due to structural issues. A study of 25 people taking PrEP and 18 providers of PrEP care identified several reasons for the PrEP discontinuation,8 including side effects and lack of perceived risk. In addition, a lack of housing caused 1 person to
stop therapy. From a provider perspective, there is often a focus on short-term clinical visits rather than long-term PrEP persistence. An analysis of 103 MSM taking PrEP found that 18% attended clinic appointments less often than the 3-month interval recommended by guidelines.9 The emergent reported barrier to PrEP adherence was insurance (39%), specifically the need for prior authorization and mailorder pharmacy mandates. In addition, systemic barriers to medical care were reported, such as poor availability of appointments, leading to medical appointment–related barriers.9 Removal of these appointment- and insurance-related barriers may help with PrEP persistence. A systematic review and metaethnography of experiences with PrEP use in cisgender men in the United States revealed interventions such as telehealth and pharmacist-prescribed approaches to PrEP distribution might reduce barriers to PrEP uptake and persistence.10 However, structural interventions were not likely to alleviate barriers in underserved communities. Of interest, a study of approximately 1,000 participants taking PrEP reported
