Recent research has shown that young black men who have sex with men (YBMSM), especially in southeastern states, have a higher incidence rate of HIV than other populations. Therefore, this population has been identified as likely benefitting from an increased use of pre-exposure prophylaxis (PrEP). “Knowledge about PrEP and access to PrEP services are known barriers to PrEP use among key populations, but my colleagues and I suspected that this was only part of the story,” explains David P. Serota, MD, MSc. “In this study, we evaluated PrEP uptake and discontinuation in YBMSM in the South, in a setting where universal education and access to PrEP were provided.”
For a study published in Clinical Infectious Diseases, the researchers examined the rate of YBMSM participants who started PrEP and later discontinued, as well as the median time to these events. The study was in tandem with an HIV incidence study of YBMSM in the Atlanta area. “Participants were followed for 2 years and offered enrollment in our PrEP program at each visit,” explains Dr. Serota. “If they reported interest, they met with a physician who confirmed eligibility and prescribed the medication.” Participants who took PrEP were tracked every 3 months to record adherence through self-report, call logs, dates of prescriptions, and a manufacturer assistance program. Participants who discontinued their PrEP use were given the option of restarting.
According to Dr. Serota, physicians should be aware of four key findings from the study:
- Multiple offers of PrEP were required before many participants indicated a desire to start. “Physicians should continue to offer PrEP over time to patients at elevated risk for HIV, even if they decline at first,” he says.
- Lab testing is only required every 3 months for patients taking PrEP; however, more frequent points of contact identified participants who had stopped and helped encourage reinitiating.
- Patients aged 18-21 are at high risk for discontinuing PrEP.
- Physicians should talk to patients about the ins and outs of PrEP use. “Physicians may be able to help patients manage side effects, cost burden, or misunderstanding of how PrEP should be taken,” explains Dr. Serota.
“An especially important finding is that patients with history of STI and who’ve had condomless anal sex were most likely to initiate PrEP,” he says (Table). “Because STI is surrogate for HIV risk, this is a very important population to offer PrEP. Patients presenting with an STI should be offered PrEP (assuming no contraindication), and fortunately, these data show that they are very likely to initiate it.”
The study found participants with fewer sexual partners were more likely to discontinue use. Research has not been able to discover why the 18-21 age group is at such a high risk of discontinuing PrEP, leading Dr. Serota to feel that understanding why is a research priority. “For some, side effects and taking a daily pill are barriers to PrEP,” he notes. “It would be nice to have multiple PrEP options to meet people’s different individual needs. Current research is looking at intermittent/on-demand dosing of PrEP, newer formulations of tenofovir/emtricitabine, injectable PrEP, implantable PrEP, prophylactic monoclonal antibodies, and the ever-elusive HIV vaccine.”
In the meantime, Dr. Serota believes progress will be made by “offering PrEP to members of key populations with high HIV incidence regardless of reported sexual activity and not giving up on patients who decline PrEP initiation at first. Be persistent if you feel someone would benefit from PrEP. Also, don’t give up promoting PrEP, even after someone discontinues; in our study, most of those who discontinued eventually restarted.”