Advertisement

Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Understanding PrEP Persistence: Provider and Patient Perspectives

Abstract

PrEP persistence, or PrEP use over time, has been shown to be short, with most PrEP users stopping within 6–12 months. Furthermore, those most vulnerable to HIV often use PrEP for shorter periods. This qualitative study explores patient, provider, and contextual factors that influence PrEP persistence. In interviews with 25 PrEP users and 18 PrEP providers in San Francisco’s safety net clinics, we analyze the perceived benefits and difficulties of taking PrEP, including structural barriers. We identify different steps in receipt of PrEP care (clinic visits and lab tests, pharmacy interactions, and medication adherence), and describe barriers and facilitators for providers and patients at each step. Our findings suggest that drop-in visits, streamlined testing, standing orders for labs, and 90-day PrEP prescriptions are highly desirable for many PrEP users. Also important are the proactive provision of adherence support and counseling, and referrals for housing, substance use, and mental health services.

Reusmen

Se ha demostrado que la persistencia de PrEP, o el uso de PrEP a lo largo del tiempo, es corto, y la mayoría de los usuarios de PrEP lo deja de tomar dentro de 6-12 meses. Además, muchas veces las personas más vulnerables al VIH usan PrEP por períodos más cortos. Este estudio cualitativo explora pacientes, proveedores y factores contextuales que influyen en la persistencia de PrEP. En entrevistas con 25 usuarios de PrEP y 18 proveedores de PrEP en las clínicas de redes de seguridad de San Francisco, analizamos los beneficios y las dificultades percibidos de tomar PrEP, incluidas las barreras estructurales. Identificamos diferentes pasos en la recepción de la atención de PrEP (visitas a clínicas y pruebas de laboratorio, interacciones de farmacia y adherencia a medicamentos) y describimos las barreras y facilitadores para proveedores y pacientes en cada paso. Nuestros hallazgos sugieren que las visitas directas, las pruebas simplificadas, las órdenes permanentes para los laboratorios y las recetas de PrEP de 90 días son muy deseables para muchos usuarios de PrEP. También es importante la provisión proactiva de apoyo y asesoramiento de adherencia, y referencias para vivienda, uso de sustancias y servicios de salud mental.

This is a preview of subscription content, log in to check access.

References

  1. 1.

    Grant RM, Anderson PL, McMahan V, Liu A, Amico KR, Mehrotra M, et al. Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infect Dis. 2014;14(9):820–9. https://doi.org/10.1016/s1473-3099(14)70847-3.

  2. 2.

    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. NEngl J Med. 2010;363(27):2587–99.

  3. 3.

    McCormack S, Dunn DT, Desai M, Dolling DI, Gafos M, Gilson R, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. The Lancet. 2016;387(10013):53–60. https://doi.org/10.1016/s0140-6736(15)00056-2.

  4. 4.

    Bae JW, Guyer W, Grimm K, Altice FL. Medication persistence in the treatment of HIV infection: a review of the literature and implications for future clinical care and research. AIDS. 2011;25(3):279–90. https://doi.org/10.1097/QAD.0b013e328340feb0.

  5. 5.

    Cramer J, Roy A, Burrell A, Fairchild C, Fuldeore M, Ollendorf D, et al. Medication compliance and persistence: terminology and definitions. Value Health. 2008;11:44–7.

  6. 6.

    Spinelli MA, Scott HM, Vittinghoff E, Liu AY, Gonzalez R, Morehead-Gee A, et al., editors. Missed Visits associated with future preexposure prophylaxis (PrEP) discontinuation among PrEP users in a municipal primary care health network. Open forum infectious diseases. Oxford: Oxford University Press; 2019.

  7. 7.

    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. https://doi.org/10.1080/09540121.2017.1286287.

  8. 8.

    Krakower D, Maloney KM, Powell VE, Levine K, Grasso C, Melbourne K, et al. Patterns and clinical consequences of discontinuing HIV preexposure prophylaxis during primary care. J Int AIDS Soc. 2019;22(2):e25250.

  9. 9.

    Liu A. Learning from Oral PrEP care retention: rates, patterns, and interventions. NIAID-NIMH behavioral and social science meeting; May 13–14, 2019.

  10. 10.

    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. https://doi.org/10.1093/cid/ciy160.

  11. 11.

    van Epps P, Maier M, Lund B, Howren MB, Beck B, Beste L, et al. Medication adherence in a nationwide cohort of veterans initiating pre-exposure prophylaxis (PrEP) to prevent HIV infection. J Acquir Immune Defic Syndr. 2018;77(3):272–8.

  12. 12.

    Zucker J, Carnevale C, Richards P, Slowikowski J, Borsa A, Gottlieb F, et al. Predictors of disengagement in care for individuals receiving pre-exposure prophylaxis (PrEP). J Int AIDS Soc. 2019. https://doi.org/10.1097/qai.0000000000002054.

  13. 13.

    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. https://doi.org/10.7448/ias.19.1.20903.

  14. 14.

    Dombrowski JC, Golden MR, Barbee LA, Khosropour CM. Patient disengagement from an HIV preexposure prophylaxis program in a sexually transmitted disease clinic. Sex Transm Dis. 2018;45(9):e62–e6464.

  15. 15.

    Scott H, Spinelli MA, Vittinghoff E, Morehead-Gee A, Nordell M, Liu A, et al. Racial/Ethnic and HIV risk category disparities in PrEP discontinuation among patients in publicly-funded primary care clinics. AIDS. 2019;33(14):2189–2195.

  16. 16.

    Greenwald Z, Beauchemin M, Benomar K, Landry G, Boissonnault M, Charest L, et al., editors. High seroconversion rates following prep discontinuance in a Montreal clinic. Boston, MA: CROI; 2018.

  17. 17.

    SFDPH. Ask about PrEP: How providers can prescribe PrEP to prevent HIV and reduce health disparities; 2017.

  18. 18.

    Spinelli MA, Scott HM, Vittinghoff E, Liu AY, Morehead-Gee A, Gonzalez R, et al., editors. Provider adherence to pre-exposure prophylaxis monitoring guidelines in a large primary care network. Open forum infectious diseases. Oxford: Oxford University Press; 2018.

  19. 19.

    CDC. Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 update.

  20. 20.

    Parsons JT, Rendina HJ, Lassiter JM, Whitfield THF, 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. https://doi.org/10.1097/qai.0000000000001251.

  21. 21.

    Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. https://doi.org/10.1191/1478088706qp063oa.

  22. 22.

    Philbin MM, Parker CM, Parker RG, Wilson PA, Garcia J, Hirsch JS. The promise of pre-exposure prophylaxis for black men who have sex with men: an ecological approach to attitudes, beliefs, and barriers. AIDS Patient Care STDs. 2016;30(6):282–90. https://doi.org/10.1089/apc.2016.0037.

  23. 23.

    Hughes SD, Sheon N, Andrew EVW, Cohen SE, Doblecki-Lewis S, Liu AY. Body/selves and beyond: Men’s narratives of sexual behavior on PrEP. Med Anthropol. 2018;37(5):387–400. https://doi.org/10.1080/01459740.2017.1416608.

  24. 24.

    Gafos M, Horne R, Nutland W, Bell G, Rae C, Wayal S, et al. The context of sexual risk behaviour among men who have sex with men seeking PrEP, and the impact of PrEP on sexual behaviour. AIDS Behav. 2019;23(7):1708–20. https://doi.org/10.1007/s10461-018-2300-5.

  25. 25.

    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.

  26. 26.

    Serota DP, Rosenberg ES, Lockard AM, Rolle C-PM, 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. https://doi.org/10.1093/cid/ciy297

  27. 27.

    Laborde ND, Spinelli MA, Scott H, editors. Uncomfortable conversations: sexual health disparities in identifying PrEP candidates. San Jose, CA: American Anthropological Association; 2018.

  28. 28.

    Lankowski AJ, Bien-Gund CH, Patel VV, Felsen UR, Silvera R, Blackstock OJJA, et al. PrEP in the real world: predictors of 6-month retention in a diverse urban cohort. AIDS Behav. 2019;23(7):1797–802. https://doi.org/10.1007/s10461-018-2296-x.

  29. 29.

    Lancki N, Almirol E, Alon L, McNulty M, Schneider JA. Preexposure prophylaxis guidelines have low sensitivity for identifying seroconverters in a sample of young black MSM in Chicago. AIDS. 2018;32(3):383–92.

  30. 30.

    Golub S, editor. PrEP messaging: taking “Risk” out of the pitch. HIVR4P; Madrid; 2018.

  31. 31.

    Calabrese SK, Underhill K. How stigma surrounding the use of HIV preexposure prophylaxis undermines prevention and pleasure: a call to destigmatize “truvada whores”. Am J Public Health. 2015;105(10):1960–4.

  32. 32.

    Calabrese SK, Earnshaw VA, Underhill K, Hansen NB, Dovidio JF. The impact of patient race on clinical decisions related to prescribing HIV pre-exposure prophylaxis (PrEP): assumptions about sexual risk compensation and implications for access. AIDS Behav. 2014;18(2):226–40. https://doi.org/10.1007/s10461-013-0675-x

  33. 33.

    Millett GA, Flores SA, Peterson JL, Bakeman R. Explaining disparities in HIV infection among black and white men who have sex with men: a meta-analysis of HIV risk behaviors. AIDS. 2007;21(15):2083–91.

  34. 34.

    Mimiaga MJ, Reisner SL, Cranston K, Isenberg D, Bright D, Daffin G, et al. Sexual mixing patterns and partner characteristics of black MSM in Massachusetts at increased risk for HIV infection and transmission. J Urban Health. 2009;86(4):602–23.

  35. 35.

    Maulsby C, Millett G, Lindsey K, Kelley R, Johnson K, Montoya D, et al. HIV among black men who have sex with men (MSM) in the United States: a review of the literature. AIDS Behav. 2014;18(1):10–25.

  36. 36.

    Sullivan PS, Peterson J, Rosenberg ES, Kelley CF, Cooper H, Vaughan A, et al. Understanding racial HIV/STI disparities in black and white men who have sex with men: a multilevel approach. PLoS ONE. 2014;9(3):e90514.

  37. 37.

    Irvin R, Vallabhaneni S, Scott H, Williams JK, Wilton L, Li X, et al. Examining levels of risk behaviors among black men who have sex with Men (MSM) and the association with HIV acquisition. PLoS ONE. 2015;10(2):e0118281.

  38. 38.

    Sullivan PS, Rosenberg ES, Sanchez TH, Kelley CF, Luisi N, Cooper HL, et al. Explaining racial disparities in HIV incidence in black and white men who have sex with men in Atlanta, GA: a prospective observational cohort study. Ann Epidemiol. 2015;25(6):445–54.

  39. 39.

    Calabrese SK, Krakower DS, Mayer KH. Integrating HIV preexposure prophylaxis (PrEP) into routine preventive health care to avoid exacerbating disparities. Am J Public Health. 2017;107(12):1883–9. https://doi.org/10.2105/ajph.2017.304061.

  40. 40.

    Stekler JD, McMahan V, Ballinger L, Viquez L, Swanson F, Stockton J, et al. HIV pre-exposure prophylaxis prescribing through telehealth. JAIDS J Acquir Immune Defic Syndr. 2018;77(5):e40–e4242.

  41. 41.

    Touger R, Wood BR. A review of telehealth innovations for HIV pre-exposure prophylaxis (PrEP). Curr HIV/AIDS Rep. 2019;16(1):113–9.

  42. 42.

    Liu AY, Vittinghoff E, von Felten P, Rivet Amico K, Anderson PL, Lester R, et al. Randomized controlled trial of a mobile health intervention to promote retention and adherence to preexposure prophylaxis among young people at risk for human immunodeficiency virus: The EPIC Study. Clin Infect Dis. 2019;68(12):2010–7.

  43. 43.

    Getz L. Texting for Help. Social Work Today. 2014;14(4).

Download references

Funding

This study was supported by Foundation for the National Institutes of Health (R01AI104309).

Author information

Correspondence to Nicole D. Laborde.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Laborde, N.D., Kinley, P.M., Spinelli, M. et al. Understanding PrEP Persistence: Provider and Patient Perspectives. AIDS Behav (2020). https://doi.org/10.1007/s10461-020-02807-3

Download citation

Keywords

  • HIV Prevention
  • PrEP
  • Persistence