Lack of health insurance is associated with delays in PrEP initiation among young black men who have sex with men in Atlanta, US: a longitudinal cohort study.

INTRODUCTION: Delays between receiving a PrEP prescription and taking a first dose increase the risk of HIV infection. This is especially relevant in populations with high HIV incidence, such as young black men who have sex with men (YBMSM) in the United States. Additionally, YBMSM have relatively low levels of health insurance. We investigated whether lack of health insurance and reliance on PrEP funding through the manufacturer assistance programme (MAP) leads to delays in initiation of PrEP. METHODS: HIV-negative YBMSM were offered PrEP as part of a prospective cohort. Enrolment began in June 2015 with follow-up through February 2019. Interested participants attended a PrEP clinician visit and received a prescription. Those with health insurance received a copay assistance card; those without insurance accessed PrEP using the MAP. The primary outcome was the days between prescription and initiation. The effect of insurance status on this delay was modelled using a Cox proportional hazards model. RESULTS AND DISCUSSION: The median delay between receipt of a PrEP prescription and taking a first dose was 12 days (IQR 3 to 32). Compared to uninsured participants, the adjusted hazard ratio for PrEP initiation for those with insurance was 2.72 (95% CI 1.82 to 4.06). The adjusted median time to initiation for insured participants was 5 days versus 21 days for those without insurance (p < 0.0001). Older age and STI diagnosis were also associated with faster PrEP initiation. Despite equivalent access to PrEP provided by the study, YBMSM without insurance had longer delays in initiation after receipt of a prescription. Overall, the observed delay in PrEP initiation increases the chances of HIV infection and the possibility of PrEP initiation after undetected seroconversion. CONCLUSIONS: The extended time period between PrEP prescription and taking a first dose increases the risk of HIV transmission. Younger YBMSM and those without health insurance had longer delays in PrEP initiation. Immediate PrEP initiation programmes could decrease the likelihood of this occurrence and mitigate the disparity in initiation between those with and without health insurance. Clinical Trial Number: NCT02503618.

Beyond the Biomedical: Preexposure Prophylaxis Failures in a Cohort of Young Black Men Who Have Sex With Men in Atlanta, Georgia.

Human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) has high biomedical efficacy; however, awareness, access, uptake, and persistence on therapy remain low among black men who have sex with men (BMSM), who are at highest risk of HIV in the United States. To date, discussions of "PrEP failure" have focused on one typology: rare, documented HIV acquisitions among PrEP users with adequate serum drug levels (ie, biomedical failure). In our cohort of HIV-negative young BMSM in Atlanta, Georgia, we continue to observe a high HIV incidence (6.2% annually at interim analysis) despite access to free PrEP services. Among 14 seroconversions, all were offered PrEP before acquiring HIV. Among these participants, we identified 4 additional typologies of PrEP failure that expand beyond biomedical failure: low PrEP adherence, PrEP discontinuation, PrEP contemplation without initiation, and PrEP refusal. We describe the 5 typologies and suggest interventions to improve PrEP effectiveness among those at highest risk.