PrEP Uptake Still Low Among Those Needing It Most

Although the preventive efficacy of pre-exposure prophylaxis (PrEP) against HIV is well known and there are 2 formulations available on the US market—Truvada (emtricitabine/tenofovir disoproxil fumarate [FTC/TDF]) and Descovy (emtricitabine/tenofovir alafenamide [FTC/TAF])—those who could most benefit from PrEP are initiating a regimen in small numbers.

New data presented at IDWeek 2021 show that young adults, women, heterosexual individuals, and Black/African American individuals, all of whom are considered high-risk groups, are slow to begin treatment with PrEP, particularly FTC/TDF. For this analysis, PrEP users were defined as having at least 1 FTC/TDF prescription within 12 months of their index date.

“There is a need to gain insights on the characteristics of high-risk individuals who do use PrEP vs those who do not use PrEP in the real world,” the authors wrote.

Data for the study years 2012-2018 were provided via interviews with HIV health care providers, a medical coder (to understand the use of codes that signify high-risk behavior or rectal bacteria infection with syphilis, chlamydia, or gonorrhea), the IBM Commercial Claims and Encounters Database, and the IBM Multi-State Medicaid Database. Each participant’s study index date was the earliest of a claim with a high-risk sexual behavior code, a rectal bacterial sexually transmitted infection [STI] code, or a second nonrectal bacterial STI within 12 months.

The findings show that those with commercial insurance who initiated PrEP within 12 months of their index date tended to be older vs PrEP nonusers (mean [SD] age, 36.7 [11.1] vs 29.6 [12.1] years), male (98.6% vs 37.1%), and homosexual (46.6% vs 1.5%). Persons with Medicaid coverage starting PrEP were more likely to be older vs PrEP nonusers (31.8 [11.6] and 25.2 [11.0] years, respectively), but still younger than those with commercial coverage, and male (77.1% vs 22.0%); a majority of both PrEP users and and nonusers in the Medicaid group were heterosexual (68.4% and 49.8%, respectively).

For the study years, when analyzed by age and insurance status, PrEP uptake rose consistently among those aged 16 to 24 years, 25 to 34 years, and 35 years and older for 2012 to 2017 (0.03% to 2.46%, 0.18% to 10.28%, and 0.14% to 13.23%, respectively) before taking slight dips in 2018 (to 2.26%, 9.62%, and 13.03%). Use among commercially insured females remained low during this same time, never rising above 0.16%, whereas among males it grew from 0.22% to 16.53%.

There was much less variation in PrEP uptake among those with Medicaid coverage, with none of the age groups rising above 1.0% and only males seeing a sizeable increase in uptake, from 0.04% to 1.99% compared with 0.0% to 0.13% seen among females.

Overall, by the end of the study, these results were seen:

• Having Medicaid coverage resulted in lower overall PrEP uptake (0.53%) vs having commercial insurance (7.30%).
• High-risk females lagged in PrEP uptake behind males.
• The youngest age group (16-24 years) saw the smallest PrEP gains vs the oldest age group (≥35 years).
• More PrEP nonusers were female and Black/African American.
• More PrEP users were classified as homosexual or bisexual.
• PrEP users had higher Charlson Comorbidity Index scores and were more likely to have comprehensive insurance coverage.

Dues to the restrictions on the sample size (only Medicaid and commercially insured claims were analyzed), the possibility of miscoding for high-risk behaviors, an inability to account for generic FTC/TDF entering the market in September 2020, and results related to FTC/TAF not being investigated, the authors’ findings may not be generalizable to a larger patient population.

However, the findings do highlight the importance of increasing PrEP availability and access to it among those most in need.

“Such insight will help healthcare stakeholders identify the populations with unmet need in PrEP service and, ultimately, target efforts to reduce new HIV infections,” they concluded.

Reference

Zhou M, Song Y, Gao E, Whiteside Y, Billmyer E, Signorovitch J. Pre-exposure prophylaxis (PrEP) prescriptions among individuals at high risk for HIV in the United States, 2012-2018. Presented at: IDWeek 2021; September 29-October 3, 2021; virtual. Poster 75. Accessed October 14, 2021. https://42bc4161a075f7e50e6f-a3bc3137033c5da42be80ce1198f9076.ssl.cf1.rackcdn.com//1799149-1632773807.pdf