Retention in Care Drives Adherence in PrEP Implementation Programs

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The proportion of gay and bisexual men who started and remained on Truvada for pre-exposure prophylaxis (PrEP) varied in real-world implementation programs in 3 mid-size U.S. cities, but retention in care was "consistently suboptimal," according to a study described in the June 13 online edition of the Journal of the International AIDS Society. Among those who did remain in care, however, adherence was good.

Controlled clinical trials have shown that Truvada (tenofovir/emtricitabine) lowers the risk of HIV infection by more than 90% if used consistently. The international iPrEx trial, for example, saw a 92% reduction in HIV risk among gay and bisexual men with drug levels showing regular use, and in an open-label extension of theiPrEx, no one who took Truvada at least 4 times per week became infected.But fewer studies have evaluated PrEP use and retention in care in real-world settings outside of clinical trials.

Philip Chan from the Miriam Hospital in Providence, Rhode Island, and colleagues looked at outcomes in PrEP clinical care implementation programs in Providence; Jackson, Mississippi; and St. Louis, Missouri, between January 2014 and September 2015.

All 3 PrEP programs were the first in their states. In Providence PrEP was offered at a sexually transmitted disease and HIV prevention clinic, in Jackson it was offered at a LGBT outpatient clinic, and in St. Louis it offered at an infectious disease specialty clinic with a majority of referrals coming from outpatient medical providers.

Participants were asked to come for follow-up every 3 months, and adherence was assessed based on self-reports.

Results

"In 3 geographically diverse PrEP implementation programs, we found suboptimal retention in care at 6 months across all sites due to a combination of structural and individual-level factors," the study authors concluded. "Diverse strategies to pay for medications, laboratory costs, and provider time, as well as interventions to promote retention in care are likely needed to reach and retain patients at highest risk for contracting HIV."

"Identifying individuals at the highest risk for acquiring HIV and financial constraints are two commonly perceived barriers to implementing PrEP," they wrote. "We were able to overcome these barriers and prescribe PrEP to diverse MSM at high risk for acquiring HIV across three clinical settings. Because a much larger fraction of patients in Mississippi was uninsured, assistance programs were critical to facilitate PrEP uptake in this setting."

"Among patients retained in care, the overwhelming majority reported adherence rates commensurate with the minimum required for PrEP efficacy," they continued. "Our results, robust across 3 sites and 3 different socio-economic environments, demonstrated that retention in PrEP-related care may be the biggest challenge in ensuring that PrEP’s protective benefits are maximized in real-world clinical settings…Interventions to improve retention will likely need to be tailored to specific economic, social, and clinical environments."

7/6/16

Reference

PA Chan, L Mena, R Patel, et al. Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three US cities. Journal of the International AIDS Society. Published online June 13, 2016.