Cargando…

Characterization of HIV Preexposure Prophylaxis Use Behaviors and HIV Incidence Among US Adults in an Integrated Health Care System

IMPORTANCE: Long-term follow-up is needed to evaluate gaps in HIV preexposure prophylaxis (PrEP) care delivery and to identify individuals at risk for falling out of care. OBJECTIVE: To characterize the PrEP continuum of care, including prescription, initiation, discontinuation, and reinitiation, an...

Descripción completa

Detalles Bibliográficos
Autores principales: Hojilla, J. Carlo, Hurley, Leo B., Marcus, Julia L., Silverberg, Michael J., Skarbinski, Jacek, Satre, Derek D., Volk, Jonathan E.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: American Medical Association 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8391097/
https://www.ncbi.nlm.nih.gov/pubmed/34436609
http://dx.doi.org/10.1001/jamanetworkopen.2021.22692
_version_ 1783743190989275136
author Hojilla, J. Carlo
Hurley, Leo B.
Marcus, Julia L.
Silverberg, Michael J.
Skarbinski, Jacek
Satre, Derek D.
Volk, Jonathan E.
author_facet Hojilla, J. Carlo
Hurley, Leo B.
Marcus, Julia L.
Silverberg, Michael J.
Skarbinski, Jacek
Satre, Derek D.
Volk, Jonathan E.
author_sort Hojilla, J. Carlo
collection PubMed
description IMPORTANCE: Long-term follow-up is needed to evaluate gaps in HIV preexposure prophylaxis (PrEP) care delivery and to identify individuals at risk for falling out of care. OBJECTIVE: To characterize the PrEP continuum of care, including prescription, initiation, discontinuation, and reinitiation, and evaluate incident HIV infections. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used data from the electronic health records (EHR) at Kaiser Permanente Northern California to identify individuals aged 18 years and older who received PrEP care between July 2012 and March 2019. Individuals were followed up from date of linkage (defined as a PrEP referral or PrEP-coded encounter) until March 2019, HIV diagnosis, discontinuation of health plan membership, or death. Data were analyzed from December 2019 to January 2021. EXPOSURES: Sociodemographic factors included age, sex, race and ethnicity, and neighborhood deprivation index, and clinical characteristics were extracted from the EHR. MAIN OUTCOMES AND MEASURES: The primary outcomes were attrition at each step of the PrEP continuum of care and incident HIV infections. RESULTS: Among 13 906 individuals linked to PrEP care, the median (interquartile range [IQR]) age was 33 (27-43) years, 6771 individuals (48.7%) were White, and 13 227 (95.1%) were men. Total follow-up was 26 210 person-years (median [IQR], 1.6 [0.7-2.8] years). Of individuals linked to PrEP care, 88.1% (95% CI, 86.1%-89.9%) were prescribed PrEP and of these, 98.2% (95% CI, 97.2%-98.8%) initiated PrEP. After PrEP initiation, 52.2% (95% CI, 48.9%-55.7%) discontinued PrEP at least once during the study period, and 60.2% (95% CI, 52.2%-68.3%) of these individuals subsequently reinitiated. Compared with individuals aged 18 to 25 years, older individuals were more likely to receive a PrEP prescription (eg, age >45 years: hazard ratio [HR], 1.21 [95% CI, 1.14-1.29]) and initiate PrEP (eg, age >45 years: HR, 1.09 [95% CI, 1.02-1.16]) and less likely to discontinue (eg, age >45 years: HR, 0.46 [95% CI, 0.42-0.52]). Compared with White patients, African American and Latinx individuals were less likely to receive a PrEP prescription (African American: HR, 0.74 [95% CI, 0.69-0.81]; Latinx: HR, 0.88 [95% CI, 0.84-0.93]) and initiate PrEP (African American: HR, 0.87 [95% CI, 0.80-0.95]; Latinx: HR, 0.90 [95% CI, 0.86-0.95]) and more likely to discontinue (African American: HR, 1.36 [95% CI, 1.17-1.57]; Latinx: 1.33 [95% CI, 1.22-1.46]). Similarly, women, individuals with lower neighborhood-level socioeconomic status (SES), and persons with a substance use disorder (SUD) were less likely to be prescribed (women: HR, 0.56 [95% CI, 0.50-0.62]; lowest SES: HR, 0.72 [95% CI, 0.68-0.76]; SUD: HR, 0.88 [95% CI, 0.82-0.94]) and initiate PrEP (women: HR, 0.71 [95% CI, 0.64-0.80]; lower SES: HR, 0.93 [95% CI, 0.87-.0.99]; SUD: HR, 0.88 [95% CI, 0.81-0.95]) and more likely to discontinue (women: HR, 1.99 [95% CI, 1.67-2.38]); lower SES: HR, 1.40 [95% CI, 1.26-1.57]; SUD: HR, 1.23 [95% CI, 1.09-1.39]). HIV incidence was highest among individuals who discontinued PrEP and did not reinitiate PrEP (1.28 [95% CI, 0.93-1.76] infections per 100 person-years). CONCLUSIONS AND RELEVANCE: These findings suggest that gaps in the PrEP care continuum were concentrated in populations disproportionately impacted by HIV, including African American individuals, Latinx individuals, young adults (aged 18-25 years), and individuals with SUD. Comprehensive strategies to improve PrEP continuum outcomes are needed to maximize PrEP impact and equity.
format Online
Article
Text
id pubmed-8391097
institution National Center for Biotechnology Information
language English
publishDate 2021
publisher American Medical Association
record_format MEDLINE/PubMed
spelling pubmed-83910972021-09-14 Characterization of HIV Preexposure Prophylaxis Use Behaviors and HIV Incidence Among US Adults in an Integrated Health Care System Hojilla, J. Carlo Hurley, Leo B. Marcus, Julia L. Silverberg, Michael J. Skarbinski, Jacek Satre, Derek D. Volk, Jonathan E. JAMA Netw Open Original Investigation IMPORTANCE: Long-term follow-up is needed to evaluate gaps in HIV preexposure prophylaxis (PrEP) care delivery and to identify individuals at risk for falling out of care. OBJECTIVE: To characterize the PrEP continuum of care, including prescription, initiation, discontinuation, and reinitiation, and evaluate incident HIV infections. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used data from the electronic health records (EHR) at Kaiser Permanente Northern California to identify individuals aged 18 years and older who received PrEP care between July 2012 and March 2019. Individuals were followed up from date of linkage (defined as a PrEP referral or PrEP-coded encounter) until March 2019, HIV diagnosis, discontinuation of health plan membership, or death. Data were analyzed from December 2019 to January 2021. EXPOSURES: Sociodemographic factors included age, sex, race and ethnicity, and neighborhood deprivation index, and clinical characteristics were extracted from the EHR. MAIN OUTCOMES AND MEASURES: The primary outcomes were attrition at each step of the PrEP continuum of care and incident HIV infections. RESULTS: Among 13 906 individuals linked to PrEP care, the median (interquartile range [IQR]) age was 33 (27-43) years, 6771 individuals (48.7%) were White, and 13 227 (95.1%) were men. Total follow-up was 26 210 person-years (median [IQR], 1.6 [0.7-2.8] years). Of individuals linked to PrEP care, 88.1% (95% CI, 86.1%-89.9%) were prescribed PrEP and of these, 98.2% (95% CI, 97.2%-98.8%) initiated PrEP. After PrEP initiation, 52.2% (95% CI, 48.9%-55.7%) discontinued PrEP at least once during the study period, and 60.2% (95% CI, 52.2%-68.3%) of these individuals subsequently reinitiated. Compared with individuals aged 18 to 25 years, older individuals were more likely to receive a PrEP prescription (eg, age >45 years: hazard ratio [HR], 1.21 [95% CI, 1.14-1.29]) and initiate PrEP (eg, age >45 years: HR, 1.09 [95% CI, 1.02-1.16]) and less likely to discontinue (eg, age >45 years: HR, 0.46 [95% CI, 0.42-0.52]). Compared with White patients, African American and Latinx individuals were less likely to receive a PrEP prescription (African American: HR, 0.74 [95% CI, 0.69-0.81]; Latinx: HR, 0.88 [95% CI, 0.84-0.93]) and initiate PrEP (African American: HR, 0.87 [95% CI, 0.80-0.95]; Latinx: HR, 0.90 [95% CI, 0.86-0.95]) and more likely to discontinue (African American: HR, 1.36 [95% CI, 1.17-1.57]; Latinx: 1.33 [95% CI, 1.22-1.46]). Similarly, women, individuals with lower neighborhood-level socioeconomic status (SES), and persons with a substance use disorder (SUD) were less likely to be prescribed (women: HR, 0.56 [95% CI, 0.50-0.62]; lowest SES: HR, 0.72 [95% CI, 0.68-0.76]; SUD: HR, 0.88 [95% CI, 0.82-0.94]) and initiate PrEP (women: HR, 0.71 [95% CI, 0.64-0.80]; lower SES: HR, 0.93 [95% CI, 0.87-.0.99]; SUD: HR, 0.88 [95% CI, 0.81-0.95]) and more likely to discontinue (women: HR, 1.99 [95% CI, 1.67-2.38]); lower SES: HR, 1.40 [95% CI, 1.26-1.57]; SUD: HR, 1.23 [95% CI, 1.09-1.39]). HIV incidence was highest among individuals who discontinued PrEP and did not reinitiate PrEP (1.28 [95% CI, 0.93-1.76] infections per 100 person-years). CONCLUSIONS AND RELEVANCE: These findings suggest that gaps in the PrEP care continuum were concentrated in populations disproportionately impacted by HIV, including African American individuals, Latinx individuals, young adults (aged 18-25 years), and individuals with SUD. Comprehensive strategies to improve PrEP continuum outcomes are needed to maximize PrEP impact and equity. American Medical Association 2021-08-26 /pmc/articles/PMC8391097/ /pubmed/34436609 http://dx.doi.org/10.1001/jamanetworkopen.2021.22692 Text en Copyright 2021 Hojilla JC et al. JAMA Network Open. https://creativecommons.org/licenses/by/4.0/This is an open access article distributed under the terms of the CC-BY License.
spellingShingle Original Investigation
Hojilla, J. Carlo
Hurley, Leo B.
Marcus, Julia L.
Silverberg, Michael J.
Skarbinski, Jacek
Satre, Derek D.
Volk, Jonathan E.
Characterization of HIV Preexposure Prophylaxis Use Behaviors and HIV Incidence Among US Adults in an Integrated Health Care System
title Characterization of HIV Preexposure Prophylaxis Use Behaviors and HIV Incidence Among US Adults in an Integrated Health Care System
title_full Characterization of HIV Preexposure Prophylaxis Use Behaviors and HIV Incidence Among US Adults in an Integrated Health Care System
title_fullStr Characterization of HIV Preexposure Prophylaxis Use Behaviors and HIV Incidence Among US Adults in an Integrated Health Care System
title_full_unstemmed Characterization of HIV Preexposure Prophylaxis Use Behaviors and HIV Incidence Among US Adults in an Integrated Health Care System
title_short Characterization of HIV Preexposure Prophylaxis Use Behaviors and HIV Incidence Among US Adults in an Integrated Health Care System
title_sort characterization of hiv preexposure prophylaxis use behaviors and hiv incidence among us adults in an integrated health care system
topic Original Investigation
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8391097/
https://www.ncbi.nlm.nih.gov/pubmed/34436609
http://dx.doi.org/10.1001/jamanetworkopen.2021.22692
work_keys_str_mv AT hojillajcarlo characterizationofhivpreexposureprophylaxisusebehaviorsandhivincidenceamongusadultsinanintegratedhealthcaresystem
AT hurleyleob characterizationofhivpreexposureprophylaxisusebehaviorsandhivincidenceamongusadultsinanintegratedhealthcaresystem
AT marcusjulial characterizationofhivpreexposureprophylaxisusebehaviorsandhivincidenceamongusadultsinanintegratedhealthcaresystem
AT silverbergmichaelj characterizationofhivpreexposureprophylaxisusebehaviorsandhivincidenceamongusadultsinanintegratedhealthcaresystem
AT skarbinskijacek characterizationofhivpreexposureprophylaxisusebehaviorsandhivincidenceamongusadultsinanintegratedhealthcaresystem
AT satrederekd characterizationofhivpreexposureprophylaxisusebehaviorsandhivincidenceamongusadultsinanintegratedhealthcaresystem
AT volkjonathane characterizationofhivpreexposureprophylaxisusebehaviorsandhivincidenceamongusadultsinanintegratedhealthcaresystem