Certain Groups Left Behind in HIV Preventive Care

Black and Hispanic individuals at risk for HIV, as well as young adults and people with substance use disorder (SUD), were more likely to experience gaps in preexposure prophylaxis (PrEP) care, a retrospective study showed.

Examining electronic health record (EHR) data of people linked to PrEP care from 2012 to 2019, Black (HR 0.74, 95% CI 0.69-0.81) and Hispanic individuals (HR 0.88, 95% CI 0.84-0.93) were less likely to receive a prescription for PrEP when compared with their white counterparts, reported Carlo Hojilla, RN, PhD, of Kaiser Permanente Northern California in Oakland, and colleagues.

Also, when prescribed these medications, Black individuals were less likely to initiate PrEP versus whites (HR 0.87, 95% CI 0.80-0.95), as were Hispanic individuals (HR 0.90, 95% CI 0.86-0.95). And PrEP discontinuation was higher among Black (HR 1.36, 95% CI 1.17-1.57) and Hispanic individuals (HR 1.33, 95% CI 1.22-1.46) as well, according to the findings in JAMA Network Open.

The study also found that individuals with SUD were less likely to get a PrEP prescription (HR 0.88, 95% CI 0.82-0.94), initiate treatment (HR 0.88, 95% CI 0.81-0.95), and stay on therapy (HR 1.23, 95% CI 1.09-1.39). Disparities in the PrEP continuum of care were also observed among women and individuals of lower socioeconomic status, the researchers reported.

“Many of these groups are higher risk for HIV as well,” Joyce Jones, MD, MS, of Johns Hopkins University School of Medicine in Baltimore, told MedPage Today. “All of the findings correlate to what we see in the clinic.”

“As a clinician in HIV and HIV prevention, this is something we’re all struggling with,” said Antonio Urbina, MD, of Mount Sinai in New York City. “Starting next year, there will be a long-acting injectable given every 3 months, I think this will open the door to address these disparities.”

In general, older adults (age 45 or over) were more likely to receive a PrEP prescription (HR 1.21, 95% CI 1.14-1.29), initiate treatment (HR 1.09, 95% CI 1.02-1.16), and stay on treatment (HR 0.46, 95% CI 0.42-0.52), as compared with younger adults (age 25 or below).

Despite recent declines in HIV infections, Hojilla and coauthors noted that a “disproportionate burden of new HIV infections” occur among minorities and men who have sex with men. “Characterizing gaps at each step of the PrEP continuum of care and identifying individuals at risk of attrition could facilitate the development and prioritization of interventions to maximize PrEP impact and equity,” the team wrote.

For their study, Hojilla’s group studied EHR data on 13,906 insured patients treated at Kaiser Permanente Northern California. Outcomes assessed included PrEP prescription, initiation, discontinuation, reinitiation, and HIV incidence. Initiation was defined by a filled prescription, and discontinuation occurred when over 120 days lapsed without a PrEP refill.

The study found an overall HIV incidence rate of 0.35 (95% CI 0.28-0.43) new infections per 100 person-years.

This included a rate of 0.87 (95% CI 0.63-1.21) new infections per 100 person-years for those who were never prescribed PrEP, 1.06 (95% CI 0.62-1.83) new infections per 100 person-years for those prescribed PrEP but who did not initiate treatment, and 1.28 (95% CI 0.93-1.76) new infections per 100 person-years among patients who discontinued PrEP but failed to re-initiate it. No persistent PrEP users acquired HIV during the study.

“It was really encouraging to see that a vast majority of the individuals who were linked to PrEP care started PrEP, and that we saw no new HIV infections among those who remained persistent on PrEP,” Hojilla told MedPage Today. “But we know from other studies that individuals from minoritized communities face multiple individual-, social-, and structural-level barriers to PrEP access and persistence.”

“While some PrEP discontinuations are appropriate, the high rate of incident HIV infection in those who discontinued suggests the need to re-engage with those individuals who could continue to benefit from PrEP,” Hojilla added.

In all, 88.1% received a PrEP prescription, and nearly all of these individuals (98.2%) started therapy. With a median follow-up of 1.6 years, 52% stopped PrEP at least one time, and 60.2% of these individuals restarted treatment. Discontinuation rates were highest within 2 years of initiation.

“It seems more that cost, competing needs, stigmas, are more likely to contribute to the discontinuation of care rather than the medications,” said Jones, who was not involved in the study.

Median age of the group was 33 years, 7% of the cohort were Black, 21% were Hispanic, and less than half were white. In this predominantly male (95%) cohort, one-fourth had alcohol use disorder, 7.8% had an SUD, and 3.9% were on public health insurance.

Study limitations included the reliance on pharmacy records and the potential for overestimating discontinuations and underestimating HIV incidence, the authors acknowledged. The findings also may not be generalizable women (who made up roughly 5% of the cohort) and the uninsured, they noted.