Which PrEP Users Fail to Stick With It?

SEATTLE — Disparities in insurance type and patient demographics were associated with non-adherence to pre-exposure HIV prophylaxis (PrEP), a researcher said here.

Only about a third of Medicaid insured PrEP users persisted on PrEP for 12 months compared to more than half of commercially insured users, reported Ya-Lin Huang, PhD, of the CDC.

There were also several notable demographic disparities: female sex, younger age, rural location, and black race/ethnicity were all associated with non-persistent use of PrEP, Huang said at a Conference on Retroviruses and Opportunistic Infections press conference.

Increasing PrEP uptake is a key component of the plan to help end the HIV epidemic in the U.S., as outlined by Anthony Fauci, MD, head of the National Institute of Allergy and Infectious Diseases, in a special presentation here on Monday. He said that 1.1 million Americans need PrEP, but fewer than one-quarter are now on it. The goal would be to increase that to half of high-risk people, Fauci said.

But getting on PrEP doesn’t mean patients stay on PrEP. Huang said it requires continuous use to be effective, and discontinuing PrEP while still at risk of acquiring HIV could result in an infection. It’s hoped that increasing PrEP use with high persistence and adherence will reduce HIV incidence.

Press conference moderator Sharon Hillier, PhD, of the University of Pittsburgh, who was not involved with the research, told MedPage Today that tackling this problem of non-persistent PrEP use is key to rolling out PrEP to more patients.

“The larger question is what’s driving that non-persistence and how can we drill down and make it easier to fit prevention into people’s lives, because that’s where we’re missing the boat,” she said.

Huang and colleagues examined two cohorts of PrEP users, from the IBM’s MarketScan commercial and Medicaid databases, both from 2011-2016. Participants were ages 18-64, had initiated PrEP from 2012-2016, and were continuously enrolled in a health plan 6 months before and 6 months after the first PrEP prescription date.

A “gap” in use was defined as >30 days between refills, and if the prescription was not refilled by that time, it was defined as “non-persistence.”

The analysis covered 7,250 users with commercial insurance and 349 with Medicaid. Nearly all users on commercial insurance were men, nearly all resided in urban areas, and about 60% were ages 25-44. In the Medicaid group, almost 80% were men, two-thirds were ages 25-44, and 43% were white and 23% black.

PrEP users on Medicaid persisted for less time than commercially insured users (median 7.6 vs 14.5 months). Men persisted longer than women (median 14.5 months vs 6.9 months).

Persistence increased with age in both cohorts. Also, in the Medicaid cohort, black users persisted for less time than white users (median 4.1 vs 8.5 months).

“It is concerning that some populations with low persistence in our study were among those with the highest rates of HIV diagnosis, such as young black men,” Huang said at the presentation.

When asked to speculate about reasons for non-persistence, she cited “lack of transportation and lack of access to healthcare.” The next step would be to explore the reasons in more detail, such as how access barriers differ among subpopulations, Huang said.