Adherence to Daily Oral TDF/FTC for PrEP in Community Health Center Populations: The Sustainable Health Center Implementation PrEP Pilot (SHIPP) Study.

The prevention effectiveness of oral preexposure prophylaxis (PrEP) is highly dependent on medication adherence but no validated longer term PrEP adherence measures are readily available for use by primary care clinicians caring for diverse populations. We compared two self-report measures (number of doses missed in past 7 days and day-by-day past week pill taking) to results of tenofovir concentrations in dried blood spot (DBS) samples at quarterly visits over the first 12 months of PrEP use. 1420 men and women in five US community health centers enrolled in a medication adherence substudy. For 3, 6, 9 and 12 months, the respective percentages of persons with self-report vs DBS levels consistent having taken all 7 doses in the week prior were 71% (51%), 70% (47%), 71% (46%) and 69% (44%). Conversely, the percentage of participants reporting taking 0-1 doses in the week prior by self-report vs DBS drug levels at 3, 6, 9 and 12 months consistent with this level of nonadherence of 6% (9%), 5% (10%), 8% (9%), and 9% (15%). The estimated risk of low adherence (estimated 0-1 doses in the week prior) was higher for participants of Black (RR 1.60, CI 1.09-2.34) or "Other" race (RR 1.62, CI 0.99-2.65) compared with participants of White race; being a transgender female (RR 2.31, CI 1.33-4.02) compared to men who have sex with men; or enrollment at a study site with less experience in the provision of PrEP. The estimated risk of low adherence by DBS was lower for participants with a higher number of sex partners in the past 3 months and those having a bachelor's degree or higher. More work is needed to provide clinicians with measures to assess medication adherence in diverse US populations being prescribed PrEP to support its effective use in reducing HIV acquisition in individuals and at the community level.

A preliminary study of African-American physician involvement in the care of HIV-infected patients.

In 1995, questionnaires were sent to the mailing list of the National Medical Association (NMA). The mail responses were supplemented by questionnaires distributed at the NMA annual meeting. Of the 709 respondents, approximately 63% were primary care providers, pediatricians, or obstetrician-gynecologists; 72% were treating from zero to 10 human immunodeficiency virus (HIV) patients while 9% were treating > 90 HIV patients; and 12% had been treating HIV patients > 10 years. The majority of these patients were African American; male-to-male sex and injecting drugs were the two major risk factors. Complexity of HIV care and lack of reimbursement were the principal barriers to providing HIV care. The burden of providing HIV care is borne by a relatively small number of physicians, and African-American physicians are actively involved in this care. Programs are needed to increase the number of African-American providers treating HIV patients and to provide appropriate reimbursement for providing this care.

An assessment of Ryan White Title IIIb HIV early intervention programs in Region VI of the United States Public Health Service.

A survey was conducted of 15 early intervention programs in Region VI of the United States Public Health Service (USPHS) to determine when human immunodeficiency virus (HIV)-infected clients assessed care. Data were collected from 672 HIV-infected patients who received medical care between March 1991 and July 1993. Eighty-four percent were male, 42% were white, 35% were African-American, 22% were Hispanic, and less than 1% defined themselves as "other." Information also was obtained on HIV risk factors and CD4 counts on entry to the facility. Thirty percent of patients had entry CD4 counts > 500/mm3, 55% had counts between 499 and 200/mm3, and 25% < 200/mm3. The distribution of entry CD4 counts were similar to those reported from two large, urban, public-hospital HIV clinics. The most common risk factor for all ethnicities was male-to-male sex (53%), followed by heterosexual exposure (17%), and injection drug use (16%). The results indicate that the majority of clients who initially present to Title IIIb "early intervention" programs in Region VI are of ethnic minority groups. Based on entry CD4 counts, patients in Title IIIb programs present late with one fourth at acquired immunodeficiency syndrome (AIDS)-defining levels. Regardless of ethnicity, male-to-male sex was the highest risk factor in this region. These findings have significant implications for the targeting of specific populations for outreach and for possibly reallocating funds for future planning of Ryan White Comprehensive AIDS Emergency Care Act programs.