Preexposure Prophylaxis for HIV Prevention in a Large Integrated Health Care System

Adherence, Renal Safety, and Discontinuation

Bibliographic Data

ID23360738
AuthorsJulia L Marcus (0000-0002-8552-414X, Kaiser Permanente, corresponding author), Leo B Hurley (0000-0003-2208-3786, Kaiser Permanente, corresponding author), Charles Bradley Hare (Department of Adult and Family Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA; and), Dong Phuong Nguyen (Kaiser Permanente San Francisco Medical Center), Tony Phengrasamy (Kaiser Permanente San Francisco Medical Center), Michael J Silverberg (0000-0001-9322-1395, Kaiser Permanente, corresponding author), Juliet E Stoltey (Division of Infectious Diseases, University of California, San Francisco, CA.), Juliet Stoltey (University of California, San Francisco), Jonathan E Volk (Kaiser Permanente San Francisco Medical Center)
Year2016
Volume73
Issue5
Pages540-546
Publication date2016-12-15
Peer ReviewedYes
Open AccessNo
TypeARTICLE
VenueJAIDS Journal of Acquired Immune Deficiency Syndromes (JOURNAL)
Journal identifiersISSN: 1525-4135 • E-ISSN: 1944-7884
PublisherOvid Technologies (Wolters Kluwer Health) (PUBLISHER)
DOI10.1097/qai.0000000000001129
PMID27851714
OpenAlexW2466146762
LanguageEN
Citations received58
References cited32

BACKGROUND: Placebo-controlled and open-label studies have demonstrated the safety and efficacy of daily oral preexposure prophylaxis (PrEP) in preventing HIV infection, but data are limited on real-world PrEP use. METHODS: We conducted a cohort study from July 2012 through June 2015 of Kaiser Permanente Northern California members initiating PrEP. We assessed pharmacy refill adherence and discontinuation, decreases in estimated glomerular filtration rate (eGFR), and sexually transmitted infection (STI)/HIV incidence. RESULTS: Overall, 972 individuals initiated PrEP, accumulating 850 person-years of PrEP use. Mean adherence was 92% overall. Black race/ethnicity [adjusted risk ratio (aRR) 3.0; 95% confidence interval: 1.7 to 5.1, P < 0.001], higher copayments (aRR 2.0; 1.2 to 3.3, P = 0.005), and smoking (aRR 1.6; 1.1 to 2.3, P = 0.025) were associated with <80% adherence. PrEP was discontinued by 219 (22.5%); female sex (aRR 2.6; 1.5 to 4.6, P < 0.001) and drug/alcohol abuse (aRR 1.8; 1.3 to 2.6, P = 0.002) were associated with discontinuation. Among 909 with follow-up creatinine testing, 141 (15.5%) had an eGFR <70 mL·min·1.73 m and 5 (0.6%) stopped PrEP because of low eGFR. Quarterly STI positivity was high and increased over time for rectal chlamydia (P < 0.001) and urethral gonorrhea (P = 0.012). No HIV seroconversions occurred during PrEP use; however, 2 occurred in individuals who discontinued PrEP after losing insurance coverage. CONCLUSIONS: PrEP adherence was high in clinical practice, consistent with the lack of HIV seroconversions during PrEP use. Discontinuation because of renal toxicity was rare. STI screening every 6 months, as recommended by current guidelines, may be inadequate. Strategies are needed to increase PrEP access during gaps in insurance coverage.

Chlamydia · Confidence interval · Discontinuation · Gonorrhea · Human immunodeficiency virus (HIV) · Incidence (geometry) · Men who have sex with men · Pre-exposure prophylaxis · Rate ratio · Relative risk · Syphilis · HIV/AIDS Research and Interventions · Immunology · Internal Medicine · Medicine · Pneumocystis jirovecii pneumonia detection and treatment · Reproductive tract infections research