Improved HIV pre-exposure prophylaxis (PrEP) uptake will be necessary for HIV eradication initiatives. Offering PrEP at the time of HIV testing can improve uptake by avoiding delays between HIV screening and initiation of PrEP typical in the traditional clinic setting. We instituted an immediate PrEP initiation program and assessed predictors of PrEP interest, initiation, and linkage.
Between November 2018 and February 2020, PrEP-eligible individuals who presented to a community-based sexual health clinic in San Diego, California were assessed for interest in immediate PrEP initiation (I-PrEP). Interested individuals were referred to a study pharmacist to receive a free 30-day supply of PrEP as early as same day and within 7 days of HIV testing, and were also linked to a community PrEP care provider. Demographic, behavioral, and sexually transmitted infection (STI) data were collected. Univariable and multivariable analyses were conducted to determine predictors of PrEP interest, initiation, linkage, and retention in care at 3 months.
Out of 2,149 individuals who presented for HIV/STI testing, 1,348 were eligible for PrEP, out of whom 517 (38.4%) were interested in starting PrEP and referred to the study pharmacist. Among those referred to the pharmacist, 333 (24.7%) actually started PrEP, 278 (20.6%) were linked to PrEP care, and, among those with follow-up, 78 (5.6%) remained in care at 3 months (Figure). Among predictors of multiple PrEP outcomes: testing positive for gonorrhea predicted PrEP interest (aOR 2.44: 95%CI 1.48-4.02), initiation (aOR 5.00: 95%CI 2.20-11.39), and linkage (aOR 2.31: 95%CI 1.26-4.25). Non-Black race predicted both PrEP initiation (aOR Black 0.50: 95%CI 0.27-0.95) and linkage (aOR Black 0.32: 95%CI 0.16-0.64). Having private health insurance predicted both linkage (aOR 1.85: 95%CI 1.28-2.67) and retention (aOR 3.94: 95%CI 1.77-8.75).
Immediate PrEP initiation in a sexual health clinic was feasible, although only a minority of PrEP-eligible persons initiated PrEP and remained in care at 3 months. Having gonorrhea was a strong predictor of PrEP uptake. Being non-Black race and having private health insurance also predicted PrEP uptake, consistent with racial/ethnic and socioeconomic barriers to PrEP usage. Greater support is needed at each step of the PrEP initiation continuum to improve the implementation of similar programs.