Pre-exposure Prophylaxis Uptake and Discontinuation Among Young Black Men Who Have Sex With Men in Atlanta, Georgia: A Prospective Cohort Study

Abstract

Background: Human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) has great potential to reduce HIV incidence among young black men who have sex with men (YBMSM); however, initiation and persistence for this group remain low. We sought to understand the patterns and predictors of PrEP uptake and discontinuation among YBMSM in Atlanta, Georgia.

Methods: PrEP was offered to all participants in a prospective cohort of YBMSM aged 18-29 years not living with HIV. Time to PrEP uptake, first discontinuation, and final discontinuation were assessed using the Kaplan-Meier method. Cox proportional hazard models were used to identify predictors of uptake and discontinuation.

Results: After 440 person-years of follow-up, 44% of YBMSM initiated PrEP through the study after a median of 122 days. Of PrEP initiators, 69% had a first discontinuation and 40% had a final discontinuation during the study period. The median time to first PrEP discontinuation was 159 days. Factors associated with PrEP uptake included higher self-efficacy, sexually transmitted infection (STI), and condomless anal intercourse. Factors associated with discontinuation included younger age, cannabis use, STI, and fewer sex partners. HIV incidence was 5.23/100 person-years (95% confidence interval [CI], 3.40-7.23), with a lower rate among those who started PrEP (incidence rate ratio, 0.39; 95% CI, .16-.92).

Conclusions: Persistent PrEP coverage in this cohort of YBMSM was suboptimal, and discontinuations were common despite additional support services available through the study. Interventions to support PrEP uptake and persistence, especially for younger and substance-using YBMSM, are necessary to achieve full PrEP effectiveness.

Clinical trials registration: NCT02503618.

Keywords: MSM; PrEP; cannabis use; substance use; young black men who have sex with men.

© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.

Figures

Figure 1.

Pattern of pre-exposure prophylaxis (PrEP) discontinuation among young black men who have sex with men. Tree diagram represents the patterns of discontinuations and restarts among 131 participants who initiated PrEP. Each discontinuation represents ≥14 days off of PrEP. The median time (in days) to reinitiation is presented.

Figure 2.

Cumulative incidence plot of time to first dose of PrEP (PrEP uptake). Participants taking PrEP at baseline (n = 19) are excluded from this plot. Abbreviation: PrEP, pre-exposure prophylaxis.

Figure 3.

Kaplan-Meier survival plot of time to first and final pre-exposure prophylaxis discontinuation. Abbreviation: PrEP, pre-exposure prophylaxis.