PrEP Rates Lowest Among Persons at Highest Risk of HIV With Medicaid Coverage

Individuals at high risk of contracting HIV and who had commercial health insurance coverage adhered to their pre-exposure prophylaxis (PrEP) regimens more than twice as long as persons covered by Medicaid, according to study findings in Clinical Infectious Diseases.

Persistence was also shown to be highest among men, White individuals, and those aged 55 to 64 years.

“The United States Preventive Services Task Force recommends clinicians offer PrEP to persons at high risk of acquiring HIV,” the study authors wrote. “It is estimated that approximately 1.1 million persons in the United States are at risk of HIV acquisition and could benefit from taking PrEP, yet only 7% received a PrEP prescription in 2016.”

Consistent weekly PrEP use (at least 4 doses/week) is over 90% effective at preventing HIV in men who have sex with men alone, but this high rate starts to drop in the week after PrEP stoppage, they added, “and persons can acquire HIV infection soon after PrEP is discontinued.”

Whereas similar previous studies have zeroed in on PrEP adherence in closed health care systems, this study sought results generalizable to wider patient populations.

The investigators from the CDC compared data on insured Americans between January 1, 2012, and December 31, 2017, from the IBM MarketScan Commercial Claims and Encounter (commercial coverage group; n = 11,807) and the IBM MarketScan Multi-State Medicaid (Medicaid coverage group; n = 647) databases. Most patients were male (97.7% and 77.6%, respectively) and aged 25 to 44 years (60.8% and 63.2%). All had to have at least 1 filled PrEP prescription.

Their analyses revealed these findings:

• Uninterrupted PrEP use was 13.7 (95% CI, 13.3-14.1) months among the commercial group vs 6.8 months (95% CI, 6.1-7.6; P < .0001) among the Medicaid group.
• PrEP use for at least 12 continuous months was more common in the commercial group than the Medicaid group (54.0% vs 29.9%) and in male vs female patients (54.4% vs 36.7%).
• Persistent PrEP use was more than twice as long in male compared with female patients (13.9 [95% CI, 13.4-14.3] vs 6.9 [95% CI, 5.6-8.7] months) and in older (45-64 years) vs younger (18-44 years) women (12.2 [95% CI, 10.2-16.1] vs 5.6 [95% CI, 4.5-6.9] months).
• Female patients with Medicaid coverage had reduced PrEP persistence overall compared with male patients: 5.8 (95% CI, 4.1-7.1) vs 7.1 (95% CI, 6.2-8.1) months.
• Female patients with Medicaid coverage were less likely to continue PrEP after 12 months compared with male patients: 20.8% vs 32.4%.
• In the commercial and Medicaid groups, older (45-54 years) users had longer median PrEP persistence than younger (18-24 years) users:
  • Commercial: 18.9 (95% CI, 17.6-20.6) vs 7.4 (95% CI, 6.9-8.2) months
  • Medicaid: 8.9 (95% CI, 7.3-10.6) vs 5.1 (95% CI, 4.0-6.7) months
• In the Medicaid group, Black individuals had the shortest PrEP persistence compared with White and other race/ethnicity users: 4.7 vs 7.3 vs 8.0 months, respectively.

For this study, PrEP was considered discontinued on the 31st day after a prescription should have been refilled and persistence defined as “the length of time that a person continued to refill PrEP prescriptions without an interruption of more than 30 days.”

The authors note how their findings add to the current body of evidence of disparities in PrEP uptake and persistence.

“Previous studies have identified similar patient factors associated with PrEP discontinuation, including female sex, younger age, black race/ethnicity, and uninsured status,” they said. “A recent study of PrEP prescriptions dispensed by a national pharmacy chain also found that more than half of PrEP users persisted for a year, with women and younger persons persisting with PrEP the shortest time.”

Possible causes of these disparities include stigma, financial issues, and lack of both health care access and support. Solutions to close these care gaps include tailoring PrEP interventions for younger patients (eg, more frequent visits, more intensive counseling, long-acting injectables) and for Black individuals (by addressing social determinants of health).

“PrEP will only be effective in preventing new HIV infections if it is used adherently and persistently by persons who are at risk of acquiring HIV,” the authors concluded. “A better understanding of reasons for discontinuing PrEP will inform interventions to support PrEP use by persons with substantial risk of HIV acquisition.”

Reference

Huang Y-LA, Tao G, Smith DK, Hoover KW. Persistence with human immunodeficiency virus pre-exposure prophylaxis in the United States, 2012–2017. Clin Infect Dis. 2021;72(3):379-385. doi:10.1093/cid/ciaa037