A third of young men who have sex with men (MSM) who take pre-exposure prophylaxis (PrEP) discontinue it within a six-month period, investigators from the United States report in AIDS and Behavior. Common reasons for stopping included being unable to get an appointment with a doctor and problems with insurance coverage
“The two most common factors for discontinuation of use…are systemic barriers, indicating that more needs to be done to increase PrEP for those who are at high HIV risk,” write the investigators. “One potential solution may be to enable service providers, such as local health departments, to incorporate proactive services for high-risk HIV-negative individuals.”
None of the men who stopped PrEP reported 100% condom use and over 40% said they never used condoms after discontinuation.
PrEP is a highly effective method of HIV prevention. If taken consistently, it can reduce the risk of HIV infection by over 90%.
Little is known about the reasons why people discontinue PrEP. Investigators therefore designed a study analysing rates and reasons for PrEP discontinuation and sexual behaviour after stopping PrEP involving young sexually active MSM PrEP users in Chicago.
Participants were aged between 16 and 29 years. At follow-up appointments, the men were asked if they had taken or discontinued PrEP in the previous six months. Individuals who reported stopping PrEP were asked why and a sub-set were asked about their condom use after stopping PrEP.
The study took place between 2015 and 2017. During this period, 197 participants reported using PrEP in the previous six months. A third of these men (65) said they had stopped using PrEP by the time of the follow-up interview. Black and Hispanic men were significantly more likely to report discontinuation than white men (p = 0.026).
“These findings are particularly concerning given that black and Hispanic MSM are also those at greatest risk of HIV,” write the researchers. “These emerging racial disparities in discontinuation may be due to structural differences between populations, for example differences in access to healthcare facilities or access to or cost of insurance.”
A total of 29 individuals were asked about discussions they had had with their medical providers concerning PrEP use. Most (79%) had not spoken to their doctor before stopping the treatment.
Thirty-five men were asked about their sexual behaviour after treatment discontinuation. Over half (58%) said they continued to have anal sex, with 41% of these men saying they never used condoms, 35% reporting they used condoms less than 50% of the time and 24% stated they used condoms most of the time. None said they always used condoms.
Common reasons for stopping PrEP included being unable to get to an appointment with a doctor (22%), insurance problems (20%), individuals no longer perceived themselves to be at risk of HIV (19%), concerns about side-effects (9%), cost (9%), adherence (8%) and stigma (6%).
“We observed several important factors which must be considered and addressed if PrEP usage is to continue to rise,” conclude the authors. “Further research must be conducted to look beyond medication adherence and develop a better understanding about which other prevention strategies are used following purposeful PrEP discontinuation.”
Morgan E et al. High rate of discontinuation may diminish PrEP coverage among young men who have sex with men. AIDS and Behavior, online edition. Doi.org/10.1007/s10461-018-2125-2 (2018).