AIDS and Behavior

, Volume 23, Issue 10, pp 2730–2740 | Cite as

Mind the gaps: prescription coverage and HIV incidence among patients receiving pre-exposure prophylaxis from a large federally qualified health center in Los Angeles, California

Mind the Gaps: Cobertura de recetas e incidencia de VIH entre pacientes recibiendo profilaxis pre-exposición de un centro de salud grande y federalmente calificado en Los Ángeles, CA
  • Chelsea L. ShoverEmail author
  • Steven Shoptaw
  • Marjan Javanbakht
  • Sung-Jae Lee
  • Robert K. Bolan
  • Nicole J. Cunningham
  • Matthew R. Beymer
  • Michelle A. DeVost
  • Pamina M. Gorbach
Original Paper


We conducted a records-based cohort study of patients who initiated pre-exposure prophylaxis (PrEP) at a large federally qualified health center in Los Angeles, CA to characterize patterns of PrEP use, identify correlates of PrEP discontinuation, and calculate HIV incidence. Of 3121 individuals initiating PrEP between 2014 and 2017, 42% (n = 1314) were active (i.e., had a current PrEP prescription) in April 2018. HIV incidence was 0.1/100 person-years among active PrEP patients, compared to 2.1/100 person-years among patients who discontinued. Compared to patients accessing PrEP through government programs with no prescription copay, risk of discontinuation was higher among those with private insurance (ARR = 1.4, 95% CI 1.2, 1.7), or no insurance (ARR = 4.5, 95% CI 3.2, 6.4). Sixty-three percent of active PrEP patients had gaps between PrEP prescriptions, averaging one gap per year (median length = 65 days). Increasing access to free or low-cost PrEP can improve PrEP continuity.


Pre-exposure prophylaxis HIV prevention Health insurance HIV incidence 


Llevamos a cabo un estudio de cohorte basada en registros de pacientes quienes iniciaron profilaxis pre-exposición (PrEP) en un centro de salud grande y federalmente calificado en Los Ángeles, CA para caracterizar patrones del uso de PrEP, identificar correlaciones de la discontinuación de PrEP y calcular la incidencia de VIH. De los 3121 individuos quienes iniciaron PrEP entre los años 2014–2017, 42% (n = 1314) fueron activos (i.e. actualmente tenían una receta para PrEP) en abril 2018. La incidencia de VIH fue 0.1/100 persona-años entre los pacientes activos con PrEP, comparada a 2.1/100 personas-años entre los pacientes quienes lo dejaron de usar. Comparado a los pacientes accediendo a PrEP a través de programas gubernamentales sin copago para las recetas, el riesgo de discontinuación de PrEP fue más alto entre los con seguro de salud privado (RRA = 1.4, 95% CI 1.2, 1.7) o los que no tienen seguro de salud (RRA = 4.5, 95% CI 3.2, 6.4). Sesenta y tres por ciento de los pacientes activos de PrEP tenían lapsos sin recetas de PrEP, con un promedio de uno lapso por año (duración del lapso mediano = 65 días). Ampliando el acceso a PrEP gratis o con bajo costo puede mejorar la continuidad de tomar PrEP.



The authors wish to thank the PrEP navigation team, counselors, and clinicians at the Los Angeles LGBT Center. CLS was supported by the National Institute on Drug Abuse of the National Institutes of Health under award number T32DA035165. SS was supported by the National Institute of Mental Health under award number P30 MH058107. MJ was supported by the National Institutes of Health and National Institute of Allergy and Infectious Disease, grant number K01AI091861. MRB was supported by the UCLA Postdoctoral Fellowship Training Program in Global HIV Prevention Research (Currier and Gorbach, PIs); T32MH080634. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. There are no conflicts of interest to report.

Compliance with Ethical Standards

Ethical Approval

The study was approved by the Institutional Review Board at the University of California, Los Angeles (IRB#17-000717).


  1. 1.
    Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. New Engl J Med. 2010;363(27):2587–99.CrossRefGoogle Scholar
  2. 2.
    Hoots BE, Finlayson T, Nerlander L, Paz-Bailey G, National HIVBSSG. Willingness to take, use of, and indications for pre-exposure prophylaxis among men who have sex with men-20 US cities, 2014. Clin Infect Dis. 2016;63(5):672–7.CrossRefGoogle Scholar
  3. 3.
    Ocfemia MCB, Dunville R, Zhang TC, Barrios LC, Oster AM. HIV diagnoses among persons aged 13-29 years—United States, 2010-2014. Mmwr-Morb Mortal Weekly Report. 2018;67(7):212–5.CrossRefGoogle Scholar
  4. 4.
    Centers for Disease Control and Prevention. HIV Surveillance Report, 2016. 2017;28.Google Scholar
  5. 5.
    Jenness SM, Goodreau SM, Rosenberg E, Beylerian EN, Hoover KW, Smith DK, et al. Impact of the centers for disease control’s HIV preexposure prophylaxis guidelines for men who have sex with men in the United States. J Infect Dis. 2016;214(12):1800–7.CrossRefGoogle Scholar
  6. 6.
    Goodreau SM, Hamilton DT, Jenness SM, Sullivan PS, Valencia RK, Wang LY, et al. Targeting human immunodeficiency virus pre-exposure prophylaxis to adolescent sexual minority males in higher prevalence areas of the United States: a modeling study. J Adolesc Health. 2018;62(3):311–9.CrossRefGoogle Scholar
  7. 7.
    Kelley CF, Kahle E, Siegler A, Sanchez T, del Rio C, Sullivan PS, et al. Applying a PrEP continuum of care for men who have sex with men in Atlanta, Georgia. Clin Infect Dis. 2015;61(10):1590–7.CrossRefGoogle Scholar
  8. 8.
    Liu A CG, Cohen S, Bacon O, Kolber M, Amico KR, Mugavero M, Grant R, Buchbinder S editors. The spectrum of engagement in HIV prevention: proposal for a PrEP cascade. 7th International conference on HIV treatment and prevention adherence; 2012; Florida: Miami Beach.Google Scholar
  9. 9.
    Parsons JT, Rendina HJ, Lassiter JM, Whitfield TH, Starks TJ, Grov C. Uptake of HIV pre-exposure prophylaxis (PrEP) in a national cohort of gay and bisexual men in the United States. J Acquir Immune Defic Syndr. 2017;74(3):285–92.CrossRefGoogle Scholar
  10. 10.
    Nunn AS, Brinkley-Rubinstein L, Oldenburg CE, Mayer KH, Mimiaga M, Patel R, et al. Defining the HIV pre-exposure prophylaxis care continuum. AIDS. 2017;31(5):731–4.CrossRefGoogle Scholar
  11. 11.
    Serota DP, Rosenberg ES, Lockard AM, Rolle CM, Luisi N, Cutro S, et al. Beyond the biomedical: preexposure prophylaxis failures in a cohort of young black men who have sex with men in Atlanta, Georgia. Clin Infect Dis. 2018;67(6):965–70.CrossRefGoogle Scholar
  12. 12.
    Chan PA, Mena L, Patel R, Oldenburg CE, Beauchamps L, Perez-Brumer AG, et al. Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three US cities. J Int Aids Soc. 2016;19(1):20903.CrossRefGoogle Scholar
  13. 13.
    Marcus JL, Hurley LB, Hare CB, Nguyen DP, Phengrasamy T, Silverberg MJ, et al. Preexposure prophylaxis for HIV prevention in a large integrated health care system: adherence, renal safety, and discontinuation. Jaids-J Acq Imm Def. 2016;73(5):540–6.CrossRefGoogle Scholar
  14. 14.
    Arnold T, Brinkley-Rubinstein L, Chan PA, Perez-Brumer A, Bologna ES, Beauchamps L, et al. Social, structural, behavioral and clinical factors influencing retention in pre-exposure prophylaxis (PrEP) care in Mississippi. PLoS ONE. 2017;12(2):e0172354.CrossRefGoogle Scholar
  15. 15.
    Blackstock OJ, Patel VV, Felsen U, Park C, Jain S. Pre-exposure prophylaxis prescribing and retention in care among heterosexual women at a community-based comprehensive sexual health clinic. Aids Care. 2017;29(7):866–9.CrossRefGoogle Scholar
  16. 16.
    Rusie LK, Orengo C, Burrell D, Ramachandran A, Houlberg M, Keglovitz K, et al. Preexposure prophylaxis initiation and retention in care over 5 years, 2012-2017: are quarterly visits too much? Clin Infect Dis. 2018;67(2):283–7.CrossRefGoogle Scholar
  17. 17.
    Hojilla JC, Vlahov D, Crouch PC, Dawson-Rose C, Freeborn K, Carrico A. HIV pre-exposure prophylaxis (PrEP) uptake and retention among men who have sex with men in a community-based sexual health clinic. AIDS Behav. 2018;22(4):1096–9.CrossRefGoogle Scholar
  18. 18.
    Haberer JE, Bangsberg DR, Baeten JM, Curran K, Koechlin F, Amico KR, et al. Defining success with HIV pre-exposure prophylaxis: a prevention-effective adherence paradigm. Aids. 2015;29(11):1277–85.CrossRefGoogle Scholar
  19. 19.
    Pines HA, Gorbach PM, Weiss RE, Shoptaw S, Landovitz RJ, Javanbakht M, et al. Sexual risk trajectories among MSM in the United States: implications for pre-exposure prophylaxis delivery. Jaids-J Acq Imm Def. 2014;65(5):579–86.CrossRefGoogle Scholar
  20. 20.
    Shover CL, Javanbakht M, Shoptaw S, Bolan RK, Lee S-J, Parsons JT, et al. HIV preexposure prophylaxis initiation at a large community clinic: differences between eligibility, awareness, and uptake. Am J Public Health. 2018;108(10):1408–17.CrossRefGoogle Scholar
  21. 21.
    Harawa NM, McBride S, Leibowitz A, Pulsipher C, Holloway I. Examining PrEP uptake among Medi-Cal Beneficiaries in California: differences by age, gender, race/ethnicity and geographic region. California HIV/AIDS Policy Research Centers; 2018.Google Scholar
  22. 22.
    Shover CL, DeVost MA, Beymer MR, Gorbach PM, Flynn RP, Bolan RK. Using sexual orientation and gender identity to monitor disparities in HIV, sexually transmitted infections, and viral hepatitis. Am J Public Health. 2018;108(S4):S277–83.CrossRefGoogle Scholar
  23. 23.
    King A, Pulsipher CA, Holloway IW. PrEP cost analysis for covered California health plans. California HIV/AIDS Policy Research Centers; 2016.Google Scholar
  24. 24.
    Molina JM, Capitant C, Spire B, Pialoux G, Cotte L, Charreau I, et al. On-demand preexposure prophylaxis in men at high risk for HIV-1 infection. N Engl J Med. 2015;373(23):2237–46.CrossRefGoogle Scholar
  25. 25.
    Anderson PL, Glidden DV, Liu A, Buchbinder S, Lama JR, Guanira JV, et al. Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Sci Transl Med. 2012;4(151):151ra125.CrossRefGoogle Scholar
  26. 26.
    Marcus JL, Levine K, Grasso C, Krakower DS, Powell V, Bernstein KT, et al. HIV preexposure prophylaxis as a gateway to primary care. Am J Public Health. 2018;108(10):1418–20.CrossRefGoogle Scholar
  27. 27.
    Hosek SG, Rudy B, Landovitz R, Kapogiannis B, Siberry G, Rutledge B, et al. An HIV preexposure prophylaxis demonstration project and safety study for young MSM. Jaids-J Acq Imm Def. 2017;74(1):21–9.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Chelsea L. Shover
    • 1
    • 2
    • 3
    Email author
  • Steven Shoptaw
    • 4
  • Marjan Javanbakht
    • 1
  • Sung-Jae Lee
    • 1
    • 5
  • Robert K. Bolan
    • 2
  • Nicole J. Cunningham
    • 2
  • Matthew R. Beymer
    • 2
    • 6
  • Michelle A. DeVost
    • 2
    • 7
  • Pamina M. Gorbach
    • 1
    • 6
  1. 1.Department of Epidemiology, Fielding School of Public HealthUniversity of California, Los AngelesLos AngelesUSA
  2. 2.Department of Health and Mental Health ServicesLos Angeles LGBT CenterLos AngelesUSA
  3. 3.Department of Psychiatry and Behavioral SciencesStanford UniversityPalo AltoUSA
  4. 4.Departments of Family Medicine and Psychiatry and Biobehavioral Sciences, David Geffen School of MedicineUniversity of California, Los AngelesLos AngelesUSA
  5. 5.Department of Psychiatry and Biobehavioral Sciences, David Geffen School of MedicineUniversity of California, Los AngelesLos AngelesUSA
  6. 6.Division of Infectious Diseases, Department of MedicineUniversity of California, Los AngelesLos AngelesUSA
  7. 7.Department of Epidemiology and BiostatisticsUniversity of California, San FranciscoSan FranciscoUSA

Personalised recommendations