Low PrEP Uptake, Persistence in Mississippi Same-Day Prescription Program

New research demonstrated high rates of discontinuation for oral HIV pre-exposure prophylaxis (PrEP), with major barriers including medication acquirement, changes in perceived HIV risk, and stigma and misinformation around PrEP use.

Specifically, most individuals given a same-day PrEP prescription either never started the therapy or stopped use within 3 months.

These findings were published in BMC Public Health and were based on a mixed-method evaluation of a pharmacist-led, same-day PrEP program in Jackson, Mississippi.

Between November 2018 and December 2019, individuals who were deemed high-risk for HIV and were attending a non-clinical testing site were referred to a pharmacist at Express Personal Health (EPH)—a walk-in, testing-only clinic for HIV and other sexually transmitted infections affiliated with the University of Mississippi Medical Center—for same-day PrEP initiation.

The study included 121 patients, a third of which were aged younger than 25 years. Most (77%) were non-Hispanic Black, cisgender men (60%), and men who have sex with men (MSM; 59%). Additionally, 67% of patients did not have insurance, and 76% of planned payments were done through a pharmaceutical company medication assistance program.

For all 121 patients, the EPH pharmacist provided a 90-day PrEP prescription and scheduled a follow-up appointment within 3 months of giving the prescription.

To determine the extent of linkage between the initial EPH visit and ongoing clinical care, as well as identify patterns of PrEP usage and adherence, researchers cross-referenced client records from the visit with electronic health records from the 2 largest PrEP clinics in the city.

Based on this analysis, the researchers identified 4 main PrEP use patterns:

• filled a prescription and linked into care within 3 months
• filled a prescription and linked into care after 3 months
• filled a prescription and never linked into care
• never filled a PrEP prescription

The researchers learned that a quarter of patients (26%) never filled their prescription.

While 44% did pick up their prescription, they never linked into clinical care, 12% received PrEP and linked into care after 3 months, and only 18% received PrEP and linked into care within 3 months. For the 12% who waited until after the 3-month period, it resulted in a PrEP coverage gap.

Additionally, 87% of cisgender women either neither started PrEP or stopped using soon after, compared with 59% of cisgender men.

In 2021, the researchers conducted individual interviews with 26 patients representing each of the 4 PrEP use groups to help identify barriers and facilitators influencing the PrEP initiation and persistence. These qualitative interviews revealed 4 main barriers to the uptake of PrEP and solutions that can help improve same-day PrEP programs.

First, patients’ initial interest in starting PrEP was driven by their perception of HIV risk, and the same-day PrEP program itself served as a motivating factor. According to the researchers, this showed how crucial it is to provide adequate education about HIV risk in a comfortable environment.

Second, challenges in obtaining medication from the pharmacy and concerns about costs hindered PrEP initiation. The researchers said addressing these barriers may involve pharmacist training and providing on-site medication pick-up options.

Third, stigma and misinformation surrounding HIV, PrEP, and being gay were pervasive, which led patients to feel reluctant to disclose PrEP use and to have misunderstandings about the therapy’s appropriateness at an individual level.

“These finding[s] underscores a critical need to develop messaging that directly combats stigma PrEP misinformation,” the researchers said. “There is widespread HIV stigma and homophobia in Mississippi, and understanding the misinformation that is predominate in the community is key for PrEP clinic staff to be able to provide factual counter-messages to the misinformation (e.g., provide clarifying messages about statements that are misinterpreted from TV advertisements), and for clinics to be able to advertise PrEP services in a way that directly combats that misinformation.”

Fourth, perceived or experienced side effects of PrEP and a belief of low HIV risk led some patients to discontinue PrEP. According to the researchers, improving messaging about side effects and encouraging discussions with health care providers before stopping medication can mitigate this barrier. Additionally, ongoing education about HIV risk assessment is recommended to make informed decisions regarding PrEP continuation.

“Interventions focused on enhancing persistence on PrEP, helping clients understand their own HIV risk, supporting re-initiation of PrEP for those who have stopped, building confidence in clients’ PrEP usage, and facilitating PrEP re-starts should be prioritized as we enter the next phase of the EHE [Ending the HIV Epidemic in the US] initiative,” the researchers said.

Reference

Khosropour CM, Riley T, Healy E, et al. Persistence in a pharmacist-led, same-day PrEP program in Mississippi: a mixed-methods study. BMC Public Health. 2023;23(1):1130. Published 2023 Jun 13. doi:10.1186/s12889-023-16072-1