The highest HIV incidence rates in the US are among young, black MSM (YBMSM). We hypothesized that structural barriers (e.g. lack of health insurance) could limit PrEP uptake in this group. Here, we describe the implementation of an optional PrEP program as an addition to a standard package of HIV prevention services in a currently enrolling, HIV/STI incidence cohort of YBMSM.
The EleMENt study is an ongoing, observational cohort examining longitudinal interactions between substance use and HIV risk behavior among HIV-negative YBMSM aged 16-29 years in Atlanta, GA. Participants are offered comprehensive HIV risk reduction counseling, condoms and lubricant, and daily oral PrEP as non-incentivized standard of HIV prevention care. After viewing a brief educational video (whatisprep.org), men who express interest in PrEP are scheduled to see a study clinician to initiate PrEP. All costs associated with clinician visits and PrEP lab monitoring are covered by the study; participants use their health insurance and/or manufacturer assistance program to obtain the drug. All PrEP users receive adherence counseling/tools per CDC guidelines. Factors associated with PrEP uptake were assessed with unadjusted odds ratios.
Between July 2015 and September 2016, 113 HIV-negative YBMSM enrolled; 3/113 (2.7%) were taking PrEP at study entry. After viewing the video, 17/110 (15%) men reported no interest in PrEP; 31/110 (28%) men wanted to discuss PrEP at the next study visit, and 62/110 (56%) men indicated interest in starting PrEP now. Of 62 interested men, 24 (39%) have not attended a PrEP initiation appointment despite repeated scheduling attempts. Thirty-eight men (38/110; 35%) initiated PrEP; however, 6/38 (16%) subsequently discontinued PrEP. The only evaluated factor associated with PrEP uptake was STI diagnosis in the prior year (OR 3.2 95%CI 1.27, 8.2). Of 54.5 person-years of follow-up to date, 4 HIV seroconversions have occurred in the cohort (annualized incidence rate of 7.3% [95% CI 2.3, 17.7]); 3 occurred in men who initiated PrEP but were not taking it.
Despite high levels of interest, uptake and adherence to PrEP appear to be suboptimal among YBMSM in this ongoing cohort even after amelioration of structural barriers that can limit PrEP use. Implementation of PrEP as standard of HIV prevention care in observational studies is feasible. However, further research will be needed to optimize uptake and adherence for YBMSM as we are observing high HIV incidence.