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Predictors of Disengagement in Care for Individuals Receiving Pre-exposure Prophylaxis (PrEP)

Zucker, Jason MD, MSa; Carnevale, Caroline FNP, MPH, AAHIVSb; Richards, Paul MPHb; Slowikowski, Jacek MPHc; Borsa, Alexander BSb; Gottlieb, Felixd; Vakkur, Isabellae; Hyden, Christel EdDf; Olender, Susan MD, MSg; Cohall, Alwyn MDh; Gordon, Peter MDg; Sobieszczyk, Magdalena E. MD, MPHg

JAIDS Journal of Acquired Immune Deficiency Syndromes: August 1, 2019 - Volume 81 - Issue 4 - p e104–e108
doi: 10.1097/QAI.0000000000002054
Prevention Research
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Background: HIV pre-exposure prophylaxis (PrEP) reduces incident HIV infections, but efficacy depends on adherence and retention, among other factors. Substance use disorders, unmet mental health needs, and demographic factors are associated with nonadherence in HIV-infected patients; we studied whether these affect PrEP retention in care.

Methods: To investigate potential risk factors disengagement in a comprehensive HIV prevention program, we conducted a retrospective cohort analysis of individuals starting tenofovir–emtricitabine between January 1, 2015, and November 30, 2017. The primary outcome was adherence to the initial 3-visit schedule after PrEP initiation.

Results: The cohort was predominantly African American (23%) and Hispanic (46%). Race, ethnicity, substance use, patient health questionnaire 9 score, insurance, and housing status were not associated with retention at the third follow-up visit. Age <30, PrEP initiation in 2017, PrEP initiation in the sexual health clinic, and PrEP same-day start were associated with lower retention; male gender at birth, transition from post‐exposure prophylaxis (PEP) to PrEP, feeling that they could benefit from, or participating in mental health services were associated with increased retention. Overall, retention in HIV preventative care at the first follow-up visit (68%) and third follow-up visit (35%) after PrEP initiation was low.

Conclusion: Clinic services and ancillary services (such as mental health) may facilitate retention in care. In this study, select social and behavioral determinants of health were not found to be linked to retention. Focused investigation of reasons for dropout may elucidate the challenges to maintaining individuals in PrEP care and direct resource allocation to those in greatest need.

aDivisions of Infectious Diseases, Departments of Internal Medicine and Pediatrics, Columbia University Irving Medical Center, New York, NY;

bHIV Prevention Program, New York Presbyterian Hospital's Comprehensive Health Center, New York, NY;

cComprehensive Health Program (CHP), New York Presbyterian Hospital, New York, NY;

dFieldston School, New York, NY;

eBowdoin College, Brunswick, ME;

fDepartment of Family and Social Medicine, Albert Einstein College of Medicine, New York, NY;

gDivision of Infectious Diseases, Department of Internal Medicine, Columbia University Medical Center, New York, NY; and

hSociomedical Sciences, Population and Family Health, and Pediatrics, Mailman School of Public Health and Columbia University Medical Center, New York, NY.

Correspondence to: Jason Zucker, MD, MS, Divisions of Infectious Diseases, Departments of Internal Medicine and Pediatrics, Columbia University Irving Medical Center, 622 West 168th Street, 8th Floor, New York, NY 10032 (e-mail: Jz2700@cumc.columbia.edu).

J.Z. is supported by the training grant “Training in Pediatric Infectious Diseases” (National Institute of Allergy and Infectious Diseases T32AI007531) and the New York STD Prevention Training Center (Centers for Disease Control—RFA-PS14-1407). This project was funded in part by the New York City Department of Health and Mental Hygiene through a contract with Public Health Solutions. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the funders.

The authors have no conflicts of interest to disclose.

Received September 29, 2018

Accepted March 11, 2019

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