New research demonstrates high rates of discontinuation of oral HIV pre-exposure prophylaxis (PrEP), with serious barriers including drug acquisition, changes in perceived HIV risk, and stigma and misinformation surrounding PrEP use.
Specifically, most people who received a same-day PrEP prescription either never started therapy or discontinued use within 3 months.
These findings were published in BMC Public Health and are based on a mixed-methods evaluation of a same-day pharmacist-led PrEP program in Jackson, Mississippi.
Between November 2018 and December 2019, individuals deemed to be at high risk for HIV and attending a non-clinical testing site were referred to a pharmacist at Express Personal Health (EPH) – a walk-in clinic for HIV testing only and other sexually transmitted infections associated with the University of Mississippi Medical Center—to start PrEP on the same day.
The study included 121 patients, a third of whom were under the age of 25. Most (77%) were non-Hispanic black, cisgender men (60%), and men who have sex with men (MSM; 59%). Additionally, 67% of patients did not have insurance, and 76% of scheduled payments were made through a pharmaceutical company’s drug assistance program.
For all 121 patients, the EPH pharmacist provided a 90-day prescription for PrEP and scheduled a follow-up appointment within 3 months of the prescription.
To determine the degree of association between the initial EPH visit and continued clinical care, and to identify patterns of PrEP use and adherence, researchers cross-referenced client records from the visit with electronic health records from the 2 largest PrEP clinics in the city.
Based on this analysis, the researchers identified 4 main patterns of PrEP use:
- filled a prescription and was enrolled in care within 3 months
- filled a prescription and was included in care after 3 months
- filled a prescription and was never linked to care
- never filled a prescription for PrEP
The researchers learned that a quarter of patients (26%) never filled their prescription.
Although 44% picked up their prescription, they were never linked to clinical care, 12% received PrEP and were linked to care after 3 months, and only 18% received PrEP and were linked to care within 3 months. For the 12% who waited until after the 3-month period, this resulted in a gap in PrEP coverage.
Additionally, 87% of cisgender women neither started PrEP nor stopped use soon after, compared to 59% of cisgender men.
In 2021, researchers conducted individual interviews with 26 patients representing each of the 4 PrEP use groups to help identify barriers and facilitators influencing PrEP initiation and persistence. These qualitative interviews revealed 4 major barriers to PrEP adoption and solutions that can help improve same-day PrEP programs.
First, patients’ initial interest in initiating PrEP was dictated by their perception of HIV risk, and the same-day PrEP program itself served as a motivating factor. According to the researchers, this shows the importance of providing adequate education about HIV risk in a comfortable environment.
Second, challenges in obtaining medication from the pharmacy and concerns about cost hindered initiation of PrEP. The researchers said that addressing these barriers could include educating pharmacists and providing on-site medication pickup options.
Third, stigma and misinformation surrounding HIV, PrEP, and being gay were widespread, leading patients to feel reluctant to disclose PrEP use and to have misunderstandings about the appropriateness of therapy on an individual level.
“These findings[s] highlights the critical need to develop messages that directly combat PrEP stigmatization misinformation,” the researchers said. “There is widespread HIV stigma and homophobia in Mississippi, and understanding the misinformation that is prevalent in the community is key for PrEP clinic staff to be able to provide factual counter-messages to the misinformation (eg, provide clarifying messages about claims that are misconstrued by TV commercials), and for clinics to be able to advertise PrEP services in a way that directly combats this misinformation.
Fourth, perceived or experienced side effects of PrEP and the belief of low HIV risk led some patients to discontinue PrEP. According to the researchers, improving the reporting of side effects and encouraging discussions with health care providers before stopping treatment may mitigate this barrier. In addition, continued HIV risk assessment education is recommended to make informed decisions about continuing PrEP.
“Interventions focused on increasing PrEP adherence, helping clients understand their own HIV risk, supporting re-initiation of PrEP for those who have stopped, building confidence in client use of PrEP, and facilitating re-initiation of PrEP must be a priority as we enter the next phase of EHE [Ending the HIV Epidemic in the US] initiative,” the researchers said.
reference
Khosropour CM, Riley T, Healy E, et al. Adherence in a pharmacist-led same-day PrEP program in Mississippi: a mixed-methods study. BMC Public Health. 2023;23(1):1130. Published June 13, 2023. doi:10.1186/s12889-023-16072-1