Back HIV Prevention Pre-exposure (PrEP) Retention in Care Drives Adherence in PrEP Implementation Programs

Retention in Care Drives Adherence in PrEP Implementation Programs


The proportion of gay and bisexual men who started and remained on Truvada for pre-exposure prophylaxis (PrEP) varied in real-world implementation programs in 3 mid-size U.S. cities, but retention in care was "consistently suboptimal," according to a study described in the June 13 online edition of the Journal of the International AIDS Society. Among those who did remain in care, however, adherence was good.

Controlled clinical trials have shown that Truvada (tenofovir/emtricitabine) lowers the risk of HIV infection by more than 90% if used consistently. The international iPrEx trial, for example, saw a 92% reduction in HIV risk among gay and bisexual men with drug levels showing regular use, and in an open-label extension of theiPrEx, no one who took Truvada at least 4 times per week became infected.But fewer studies have evaluated PrEP use and retention in care in real-world settings outside of clinical trials.

Philip Chan from the Miriam Hospital in Providence, Rhode Island, and colleagues looked at outcomes in PrEP clinical care implementation programs in Providence; Jackson, Mississippi; and St. Louis, Missouri, between January 2014 and September 2015.

All 3 PrEP programs were the first in their states. In Providence PrEP was offered at a sexually transmitted disease and HIV prevention clinic, in Jackson it was offered at a LGBT outpatient clinic, and in St. Louis it offered at an infectious disease specialty clinic with a majority of referrals coming from outpatient medical providers.

Participants were asked to come for follow-up every 3 months, and adherence was assessed based on self-reports.


  • A total of 267 individuals were prescribed PrEP: 117 in Providence, 88 in Jackson, and 62 in St. Louis.
  • Of these, 73%, 82%, and 94%, respectively, filled their prescriptions; no factors were significantly associated with initiating PrEP in a multivariate analysis.
  • About 90% of program participants were men who have sex with men; each site had 7 or 8 female participants in serodiscordant heterosexual relationships, and Providence and Jackson each had 1 transgender participant.
  • The average ages of participants were approximately 34 years in Providence, 32 in St. Louis, and 20 in Jackson.
  • African Americans accounted for just 7% of PrEP recipients in Providence, rising to 61% in St. Louis and 72% in Jackson; Latinos accounted for 24%, 3%, and 2%, respectively.
  • 53% of participants in Jackson reported incomes below the federal poverty level, compared with 26% in Providence and 23% in St. Louis.
  • 50% in Jackson, 5% in St. Louis, and 3% in Providence did not have health insurance (either private insurance, Medicaid, or other public coverage); 65%, 21%, and 4%, respectively, used Gilead's patient assistance or co-pay programs.
  • Insurance status and medication costs were not found to be significant barriers to obtaining PrEP, and insured participants reportedly had few challenges billing for Truvada.
  • Most gay men reported recent condomless anal sex, with similar rates in the 3 cities -- 65% in Jackson, 70% in Providence, and 75% in St. Louis; 31%, 28%, and 33%, respectively, had anal sex with a known HIV-positive partner.
  • None of the participants reported injection drug use and fewer than 5% said they recently used methamphetamine, but a majority drank alcohol.
  • Among 171 patients prescribed PrEP at least 6 months beforehand, 68% of participants in Providence, 71% in Jackson, and 87% in St. Louis were still in care at 3 months; at 6 months the corresponding figures were 53%, 61%, and 63%.
  • Among those not retained at 3 months, 13%-24% never actually started PrEP, 12% were lost to follow-up (all in Jackson), and 4% stopped due to side effects (all in Providence).
  • In a multivariable analysis of only gay/bi who had started PrEP, African-Americans had a lower likelihood of being retained in PrEP care at 3 months, but no factors were associated with retention at 6 months.
  • At 3 months, 89% of participants in Providence, 96% in St. Louis, and 94% in Jackson reported taking at least 4 Truvada pills in the past week -- the level associated with a high level of protection; however, the proportions reporting this level of adherence over the past month fell to 59%, 35%, and 44%, respectively.
  • Adherence rates remained stable or improved among those still in care at 6 months.
  • 3 people in the implementation programs -- 1 in each city -- were infected with HIV during the 6-month period after being prescribed PrEP, for an incidence rate of 1.1% (3 out of 267).
  • In these cases, 1 person seroconverted prior to starting PrEP (while awaiting approval of payment), 1 had suspected acute HIV infection at the time of initiation, and 1 had confirmed poor adherence.

"In 3 geographically diverse PrEP implementation programs, we found suboptimal retention in care at 6 months across all sites due to a combination of structural and individual-level factors," the study authors concluded. "Diverse strategies to pay for medications, laboratory costs, and provider time, as well as interventions to promote retention in care are likely needed to reach and retain patients at highest risk for contracting HIV."

"Identifying individuals at the highest risk for acquiring HIV and financial constraints are two commonly perceived barriers to implementing PrEP," they wrote. "We were able to overcome these barriers and prescribe PrEP to diverse MSM at high risk for acquiring HIV across three clinical settings. Because a much larger fraction of patients in Mississippi was uninsured, assistance programs were critical to facilitate PrEP uptake in this setting."

"Among patients retained in care, the overwhelming majority reported adherence rates commensurate with the minimum required for PrEP efficacy," they continued. "Our results, robust across 3 sites and 3 different socio-economic environments, demonstrated that retention in PrEP-related care may be the biggest challenge in ensuring that PrEP’s protective benefits are maximized in real-world clinical settings…Interventions to improve retention will likely need to be tailored to specific economic, social, and clinical environments."



PA Chan, L Mena, R Patel, et al. Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three US cities. Journal of the International AIDS Society. Published online June 13, 2016.