Of the estimated 176,670 U.S. cisgender women with indications for HIV preexposure prophylaxis (PrEP), less than 10% used it in 2019, and women who initiate PrEP have higher rates of discontinuation compared with men. Large observational studies are needed to identify factors associated with PrEP discontinuation among women, particularly in safety-net settings that serve women at disproportionately high risk of HIV infection.
We conducted an observational cohort study of adult cisgender women prescribed PrEP during 2012–2019 in a national network of community health centers (OCHIN; 83% uninsured or publicly insured and 67% below the federal poverty line [FPL]). Clinical and sociodemographic data were extracted from electronic health records. We evaluated the one-year cumulative incidence of discontinuation, defined as 60 days without medication based on dates of prescriptions, and used unadjusted Cox regression models to identify factors associated with discontinuation.
Of 9741 people prescribed PrEP, 644 (7%) were cisgender women and included in the study population. Mean age was 36 years; 40% were non-Hispanic White, 31% were non-Hispanic Black, and 20% were Latina. Most were on Medicaid (45%), uninsured (27%), or on other public health insurance (3%); 74% had incomes below the FPL. Among women prescribed PrEP, the cumulative incidence of discontinuation within one year was 78% (95% CI: 74%–81%). The risk of discontinuation was higher among women who were on Medicaid (unadjusted hazard ratio [HR] 1.5, 95% CI: 1.2–2.0), uninsured (HR 2.3, 95% CI: 1.8–3.1), or on other public insurance (HR 2.3, 95% CI: 1.4–3.9) compared with those on private insurance; among women with incomes <100% of the FPL (HR 2.1, 95% CI: 1.4–3.0) or 100-200% of the FPL (HR 1.7, 95% CI: 1.1–2.5) compared with those with incomes >200% of the FPL; and among women in the South compared with those in the Midwest/Northeast (HR 1.4, 95% CI: 1.1–1.8). Race, ethnicity, and age were not associated with discontinuation.
Cisgender women account for 18% of new HIV infections in the U.S. but only 7% of people prescribed PrEP at community health centers. Among women prescribed PrEP, more than 3 in 4 discontinue within one year, and risk of discontinuation is higher among women who are underinsured, lower-income, or living in Southern states. Policy changes and novel implementation strategies are needed to ensure easy access to PrEP for women, particularly those with structural barriers to care.