Beyond the Biomedical: Preexposure Prophylaxis Failures in a Cohort of Young Black Men Who Have Sex With Men in Atlanta, Georgia

Abstract

Human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) has high biomedical efficacy; however, awareness, access, uptake, and persistence on therapy remain low among black men who have sex with men (BMSM), who are at highest risk of HIV in the United States. To date, discussions of "PrEP failure" have focused on one typology: rare, documented HIV acquisitions among PrEP users with adequate serum drug levels (ie, biomedical failure). In our cohort of HIV-negative young BMSM in Atlanta, Georgia, we continue to observe a high HIV incidence (6.2% annually at interim analysis) despite access to free PrEP services. Among 14 seroconversions, all were offered PrEP before acquiring HIV. Among these participants, we identified 4 additional typologies of PrEP failure that expand beyond biomedical failure: low PrEP adherence, PrEP discontinuation, PrEP contemplation without initiation, and PrEP refusal. We describe the 5 typologies and suggest interventions to improve PrEP effectiveness among those at highest risk.

Trial registration: ClinicalTrials.gov NCT02503618.

Figures

Figure 1.

A, Timelines in 14 participants (A–N) with human immunodeficiency virus (HIV) seroconversion occurring after preexposure prophylaxis (PrEP) was offered in the EleMENt cohort. B, Proposed framework of PrEP failure typologies, beginning with biomedical failures (case A) and expanding to include low PrEP adherence (case B), PrEP discontinuation (cases C and D), PrEP contemplation (cases E–I), and PrEP refusal (cases J–N). Systems failures are represented as a ring joining the other 4 typologies, given the cross-cutting nature of this barrier to PrEP effectiveness.