Infectious Disease

Inadequate PrEP continuum in high risk populations

September 03, 2021

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Hojilla reports that while conducting the study, he received grants from Kaiser Permanente Northern California and the National Institute on Drug Abuse, as well as an off-study salary from the San Francisco Department of Public Health. Volk does not report any relevant financial information. Please refer to the study for all relevant financial information from the other authors.


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Populations disproportionately affected by HIV were less likely to be involved in pre-exposure prophylaxis, or PrEP, a continuum of care, according to results published in JAMA Network Open.

High-risk populations included African Americans, Latinx people, adults ages 18-25, and people with substance use disorders. “Latinx” is used as a gender-neutral alternative to Latino or Latina.

Hojilla JC et al. JAMA network open. 2021; doi: 10.1001 / jamanetworkopen.2021.22692.

“The most important finding is that access to health care is critical in bringing PrEP to those who could benefit most from treatment.” J. Carlo Hojilla, RN, PhD, a postdoctoral fellow in the drug abuse treatment and services research training program at the University of California, San Francisco, told Healio Primary Care. “However, the high drop-out rates in key demographic and clinical subgroups disproportionately affected by HIV suggest that access health care alone is not enough. We need more effective strategies that address the needs and barriers of these important populations in order to involve them in PrEP care. “

The PrEP continuum of care includes linking to care, prescribing PrEP, starting PrEP, continuing care during periods of risk, and resuming care after discontinuation.

Hojilla and colleagues conducted a retrospective cohort study of 13,906 adults related to PrEP care in Kaiser Permanente’s Northern California network between July 2012 and March 2019. Of the study cohort, 48.7% were white, 95.1% were men, and the mean age was 33 years. The data were collected via electronic patient files. Researchers tracked participants from the time they were linked with care through March 2019, an HIV diagnosis, abandonment of the health plan with Kaiser Permanente, or death; the total follow-up was 26,210 person-years.

Participation in PrEP

Of those who were caregiver connected during the study period, 88.1% were prescribed PrEP (95% CI, 86.1-89.9), and of these, 98.2% (95% CI, 97.2-98.8) a PrEP, according to Hojilla and colleagues.

After starting PrEP, 52.2% (95% CI, 48.9-55.7) of participants discontinued PrEP at least once and 60.2% (95% CI, 52.2-68.3) of them started the PrEP again later. People older than 45 years were more likely to be prescribed PrEP than people aged 18-25 years (HR = 1.21; 95% CI 1.14-1.29). In addition, older people were more likely to initiate PrEP (HR = 1.09; 95% CI 1.02-1.16) and less likely to drop out (HR = 0.46, 95% CI, 0.42- 0.52).

HIV incidence

The researchers reported that the incidence of HIV, at 1.28 new infections per 100 person-years, was highest among people who stopped and did not restart PrEP. Overall, 0.98% of the study cohort was diagnosed with HIV; this included diagnoses during the PrEP eligibility assessment at the time of association with care.

Without diagnoses during the treatment period, the total HIV incidence rate was 0.35 infections per 100 person-years. The rate rose to 0.87 new infections per 100 person-years when only those who were not prescribed PrEP were included. The incidence rate increased further to 1.06 new infections per 100 person-years in those prescribed PrEP but not on the regimen.

risk groups

African Americans and Latinx individuals were less likely to receive a PrEP prescription (African Americans: HR = 0.74; 95% CI 0.69-0.81; Latinx: HR = 0.88; 95% CI 0.84– 0.93) and initiated PrEP (African American: HR = 0.87; 95% CI 0.80-0.95; Latinx: HR = 0.90; 95% CI 0.86-0.95. In addition, they were more likely to drop out of PrEP if it was initiated (African American: HR = 1.36; 95% CI 1.17-1.57; Latinx: HR = 1.33; 95% CI, 1, 22-1.46).

Prescribing rates for PrEP were also lower in women (HR = 0.56; 95% CI 0.50-0.62), people with a lower socioeconomic status (HR = 0.72; 95% CI, 0, 68–0.76) and persons with substance use disorder (HR = 0.88; 95% CI, 0.82–0.94). These population groups were also less likely to initiate PrEP (women: HR = 0.71; 95% CI: 0.64-0.80; lower socio-economic status: HR = 0.93; 95% CI , 0.87-0.99; substance use disorder: HR = 0.88; 95% CI 0.81-0.95) and were more likely to discontinue PrEP when it was initiated (women: HR = 1.99; 95% CI % CI 1.67-2.38; lower socio-economic status: HR = 1.40 95% CI, 1.26-1.57; substance use disorder: HR = 1.23; 95% CI 1.09 -1.39).

While the overall incidence of HIV in the study cohort was low, Hojilla said more work is needed to examine the effectiveness of strategies like PrEP in the real world.

“A one-size-fits-all approach is not going to work to meet the diverse needs of our patients, especially those we want to reach the most. What effective targeted interventions look like is still work in progress, but it means we need to be better tailored to our patients’ needs and the barriers they face, ”said Hojilla. “We can do this by giving individuals better choices about how to access PrEP and how to deal with care, and by offering PrEP modalities that work best for them, be it daily PrEP that PrEP on demand or hopefully soon a long-acting injectable PrEP. It also means recognizing and addressing the stigma, discrimination and structural racism of HIV and PrEP – all of which promote health inequalities. “

Family doctors are ideally positioned to address HIV risk in patients, so Jonathan Volk, MD, Co-author of the study and an infectious disease specialist at The Permanente Medical Group.

“Providing PrEP to people at risk of HIV is an incredibly effective intervention that PCPs can use to reduce the incidence of HIV,” Volk told Healio Primary Care. “Because we know that many people are reluctant to disclose behavior for fear of stigma It is also important that PCPs consider PrEP for individuals applying for PrEP, regardless of self-reported risk. “


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