Four principal themes emerged in this study, describing why Latino/a and Black transgender women and men who have sex with men discontinued their preexposure prophylaxis (PrEP) to prevent HIV.
Through structured interviews, investigators discovered 4 principal themes describing why Black and Latino/a transgender women (BLTW) and men who have sex with men (BLMSM) discontinued their preexposure prophylaxis (PrEP) to prevent HIV, along with possible solutions to increase patient support and adherence, according to the study results published in PLos One.
Compared with white MSM at 1 in 11 (9%), an estimated 50% of Black MSM and 20% of Latino MSM will acquire HIV. These disparities persist for transgender women, at 11% vs 51% and 29%, respectively.
Having a lower perceived risk of acquiring HIV if they changed their sexual behavior; having structural or logistical barriers; anticipating or experiencing adverse effects (AEs) from medication, particularly if taking feminizing hormones; and encountering adherence challenges emerged as the top themes for temporary or indefinite PrEP discontinuation following interviews with 15 BLMSM and 7 BLTW.
“Understanding the reasons for PrEP discontinuation will help inform the development of support services for these populations to remain persistent with their PrEP regimen and HIV-negative,” noted the authors, a team of investigators from University of California, Los Angeles.
They conducted baseline and 6-month follow-up interviews between January 2017 and November 2018. The mean (SD) participant age was 31.9 (9.4) years, 50% were unemployed or on disability, 54.5% had an annual income of $9999 or below, and 54.6% had Medicaid or Medicare coverage.
The overall results demonstrate that the study participants had been on PrEP for a mean (SD) 14.76 (12.55) months (range, 2-44 months) and had discontinued the therapy for a mean 6.09 (9.73) months (range, 0.5-44 months).
Regarding discontinuing PrEP, changed sexual behaviors included using condoms consistently, having fewer sexual partners, life changes that led to a drop in risky behavior, and being in a monogamous relationship. Structural and logistical barriers comprised being uninsured or having excessive out-of-pocket costs, having to re-enroll in public or private insurance programs, and needing to travel long distances for medication refills or routine PrEP visits.
Experiencing gastrointestinal issues, increasing creatinine levels, and potential long-term AEs (eg, liver damage), as well as both fear of and lack of knowledge of interactions with feminizing hormones accounted for stopping PrEP due to AEs. Justifying inconsistent use as being a good reason to stop PrEP altogether or knowing one would not remain adherent were the main adherence-related reasons for quitting PrEP.
“PrEP is an important prevention tool for BLMSM and BLTW, particularly during periods of heightened HIV risk,” the authors emphasized. “Additional support services, beyond those offered by medical providers, are needed to help BLMSM and BLTW PrEP users overcome barriers to discontinuation and assist them to remain persistent with their PrEP regimen.”
They highlighted the many trials underway that are investigating how to bolster support for BLTW and BLMSM, including using mobile technology (eg, text messaging, apps) to support adherence and testing alternative dosing strategies (eg, intermittent dosing or long-acting injectable medications). The authors also noted the importance of respecting an individual’s decision to discontinue PrEP, but to supplement that with education on how to still prevent HIV and encouragement to initiate discussions with medical support providers about medication AEs.
“Understanding the nuances of why PrEP discontinuation occurs in these populations will help inform the development of support services to help these populations remain persistent with PrEP to remain HIV uninfected,” the authors concluded. “Future research may also want to explore the narratives of long-term PrEP users who are able to effectively manage their PrEP use (ie, remaining adherent, persistent, and retained in PrEP medical care) to identify resiliency factors that may be transferrable for BLMSM and BLTW struggling with using PrEP.”
Nieto O, Brooks RA, Landrian A, Cabral A, Fehrenbacher AE. PrEP discontinuation among Latino/a and Black MSM and transgender women: a need for PrEP support services. PLoS One. Published online November 5, 2020. doi: 10.1371/journal.pone.0241340