PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of lwwopenLippincott Williams & WilkinsThis article
AIDS (London, England)
 
AIDS. 2017 March 13; 31(5): 731–734.
Published online 2017 March 1. doi:  10.1097/QAD.0000000000001385
PMCID: PMC5333727

Defining the HIV pre-exposure prophylaxis care continuum

Abstract

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy. There is little scientific consensus about how to measure PrEP program implementation progress. We draw on several years of experience in implementing PrEP programs and propose a PrEP continuum of care that includes: (1) identifying individuals at highest risk for contracting HIV, (2) increasing HIV risk awareness among those individuals, (3) enhancing PrEP awareness, (4) facilitating PrEP access, (5) linking to PrEP care, (6) prescribing PrEP, (7) initiating PrEP, (8) adhering to PrEP, and (9) retaining individuals in PrEP care. We also propose four distinct categories of PrEP retention in care that include being: (1) indicated for PrEP and retained in PrEP care, (2) indicated for PrEP and not retained in PrEP care, (3) no longer indicated for PrEP, and (4) lost to follow-up for PrEP care. This continuum of PrEP care creates a framework that researchers and practitioners can use to measure PrEP awareness, uptake, adherence, and retention. Understanding each point along the proposed continuum of PrEP care is critical for developing effective PrEP interventions and for measuring public health progress in PrEP program implementation.

Keywords: HIV prevention, linkage to care, pre-exposure prophylaxis, retention in care

Pre-exposure prophylaxis (PrEP) has demonstrated efficacy in preventing HIV [13]. Whereas PrEP use is expanding globally, there is little consensus about how to measure progress in PrEP care other than to measure the number who initiate and adhere to PrEP and then impute reductions in HIV incidence. Standard benchmarks are necessary in order to compare progress in PrEP programs. A ‘PrEP care continuum’ has been previously described as including the following: identifying individuals at risk, increasing their knowledge of PrEP, ensuring access to PrEP-related healthcare, and adherence to medications after PrEP initiation [4]. However, there is a need to revisit and expand the framework to assess progress in PrEP implementation. Therefore, we draw on more than 4 years of PrEP implementation experience [510] and propose a PrEP care continuum that assesses the multiple steps related to PrEP uptake, adherence, and retention in care.

Because PrEP is intended to reduce HIV acquisition rather than treat disease, PrEP-related outcomes differ from the HIV treatment continuum [11]. We propose that the PrEP care continuum should include the following steps:

  • (1)
    Identifying individuals at highest risk for contracting HIV
  • (2)
    Increasing HIV risk awareness among those individuals
  • (3)
    Enhancing PrEP awareness
  • (4)
    Facilitating PrEP access
  • (5)
    Linking to PrEP care
  • (6)
    Prescribing PrEP
  • (7)
    Initiating PrEP
  • (8)
    Adhering to PrEP
  • (9)
    Retaining individuals in PrEP care (see Fig. Fig.11).
    Fig. 1
    The PrEP care continuum.

The first three steps in the PrEP care continuum focus on PrEP awareness. Steps 4 to 7 are related to PrEP uptake, and steps 8 and 9 focus on adherence and retention in PrEP care. Our experiences implementing PrEP suggest that each of these steps present opportunities for patients to continue using PrEP or disengage in care [510], and are important points of intervention.

The first outcome on the PrEP care continuum is identifying populations most at risk of HIV contraction, and, therefore, suitable for PrEP, who also understand their own risk for HIV (step 2). Debate about how many Americans are suitable candidates for PrEP continues; however, the Centers for Disease Control and Prevention estimate that 25% of all MSM in the United States may benefit from PrEP [12]. In the United States, MSM are most impacted by HIV, and misperception of risk has impeded PrEP uptake among this group [13,14]. Even among those who realize they are at risk for HIV, knowledge about PrEP remains limited [15]; the third step in the Continuum is therefore PrEP awareness. A recent study in the Deep South found that among those accessing PrEP services, only 18% were MSM, even though this group represented close to 50% of incident HIV cases [16]. Addressing these awareness challenges will increase PrEP uptake.

The fourth step in the PrEP care continuum is facilitating access to PrEP care. In the United States, this involves scheduling an appointment with a medical provider who prescribes PrEP and usually requires having health insurance that covers the cost of clinical care and medications. Lack of insurance coverage may present significant barriers to engaging in PrEP care, as medications and provider fees can create financial barriers to PrEP uptake [6]. Although industry-sponsored medication assistance programs may help offset costs of PrEP, other fees related to provider time and laboratory monitoring may still not be covered [6]. Moreover, many regions of the United States do not yet have dedicated PrEP providers [17].

During the initial PrEP appointment, patients are educated about PrEP and an assessment is performed to determine whether PrEP is indicated. Among patients who have access to PrEP care services, not all patients present for and link to initial PrEP appointments (the fifth step), highlighting another opportunity to intervene. The sixth step is prescribing PrEP medications to those who meet clinical criteria. At this step, there may be opportunities to measure disengagement from care when patients do not fill their PrEP prescriptions. After PrEP has been dispensed, patients can initiate PrEP, which is the seventh step in the PrEP care continuum.

The eighth step is adherence, which includes consistently taking PrEP. Previous studies have shown that PrEP adherence is critical to efficacy [1] and can significantly reduce the risk of HIV acquisition among those who adhere [1820]. The final step of the PrEP Continuum is retention in PrEP care. Retention in PrEP care poses a significant barrier to successful implementation of PrEP programs; some studies suggest that patients who are retained in PrEP care adhere to their medications [6,18]. However, greater efforts are needed to evaluate and clarify what is meant by retention in PrEP care. Defining who is successfully retained in care presents challenges. In contrast with the HIV care continuum, in which individuals take HIV medications over their lifetime, discontinuation of PrEP does not necessarily mean that an individual is lost to care or at increased risk for HIV. The term ‘prevention effective adherence’ has been used to acknowledge HIV acquisition risk may change over time in accordance with relationship changes or decreased engagement in risky behaviors [21,22].

‘Retention in care’ has been broadly used to describe whether patients are maintained in PrEP care; however, we posit that measuring retention is a complex phenomenon. Building on the ‘prevention effective adherence’ concept, we propose four distinct categories to characterize and measure retention in PrEP care: indicated for PrEP and retained in PrEP care; indicated for PrEP and not retained in PrEP care; no longer indicated for PrEP; and lost to follow-up for PrEP care (see Fig. Fig.2).2). Our experiences implementing PrEP programs suggest that individuals change their behaviors and sexual partnerships over time [5,6]. Some individuals may not need PrEP and are not lost to follow-up; rather, they no longer meet clinical criteria for taking PrEP. Capturing each of these retention-related outcomes is important for measuring progression through the PrEP continuum, both for individual patients, and also for population health metrics.

Fig. 2
The PrEP retention continuum.

Understanding how and why patients take up, adhere, and are retained or disengage from PrEP care is critical for developing effective PrEP interventions. This proposed PrEP care continuum has some limitations; for example, in developing countries where PrEP is not yet commercially available or provided in public health systems, patients may never even have opportunities to advance through the PrEP Care Continuum. Nevertheless, this preliminary effort to define benchmarks for evaluating the impacts of PrEP programs can be useful for prioritizing interventions to enhance measures to benchmark PrEP-related progress.

Acknowledgements

Author contributions: A.S.N. lead writing and editing the article; L.B.-R. contributed to writing and editing of the article; M.M. edited the article and provided conceptual oversight; K.M. edited the article and provided conceptual oversight; and P.A.C. contributed to writing and editing.

P.A.C. received funding from National Institute of Allergy and Infectious Diseases: K23AI096923. P.A.C. and A.S.N. received funding from National Institute of Mental Health: R34MH109371, and the National Institute of Allergy and Infectious Diseases: P30AI042853. A.S.N. is supported by National Institute of Alcohol Abuse and Addiction: K01AA020228. L.B.-R. and A.S.N.'s efforts are supported by National Institute of Drug Abuse Brown Initiative in HIV and AIDS Clinical Research for Minority Communities: R25MH083620. L.B.-R.'s efforts are supported by National Institute of Drug Abuse UCLA HIV/AIDS, Substance Abuse and Trauma Training Program (HA-STTP): R25DA035692; the HIV and Other Infectious Consequences of Substance Abuse: T32DA013911; and the Lifespan/Brown Criminal Justice Research Program on HIV and Substance Use: R25DA037190.

Conflicts of interest

There are no conflicts of interest.

References

1. Grant RM, Lama JR, Anderson PL, Liu AY, Vargas L, Goicochea P, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med 2010; 363:2587–2599. [PMC free article] [PubMed]
2. Baeten JM, Donnell D, Ndase NR, Mugo NR, Campbell JD, Wangisi J, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med 2012; 367:399–410. [PMC free article] [PubMed]
3. Thigpen MC, Poloko KM, Paxton LA, Smith DK, Rose CE, Segolodi TM, et al. Antiretroviral pre-exposure prophylaxis for transmission in Botswana. N Engl J Med 2012; 367:423–434. [PubMed]
4. Kelley CF, Kahle E, Siegler A, Rosenberg ES. Applying a PrEP continuum of care for men who have sex with men in Atlanta, GA. Clin Infect Dis 2015; 6:1590–1597. [PMC free article] [PubMed]
5. Montgomery MC, Oldenburg CE, Nunn AS, Mena L, Anderson P, Liegler T, et al. Adherence to pre-exposure prophylaxis for HIV prevention in a clinical setting. PLoS One 2016; 11:e0157742. [PMC free article] [PubMed]
6. Chan PA, Mena L, Patel R, Oldenburg CE, Beauchamps L, Perez-Brumer AG, et al. Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three US cities. J Int AIDS Soc 2016; 19:20903. [PMC free article] [PubMed]
7. Parker S, Chan PA, Oldenburg CE, Hoffmann M, Poceta J, Harvey J, et al. Patient experiences of men who have sex with men using pre-exposure prophylaxis to prevent HIV infection. AIDS Patient Care STDS 2015; 29:639–642. [PMC free article] [PubMed]
8. Nunn A. Patient experiences of men who have sex with men using pre-exposure prophylaxis to prevent HIV infection. AIDS Patient Care STDS 2015; 29:639–642. [PMC free article] [PubMed]
9. Chan PA, Glynn TR, Oldenburg CE, Montgomery MC, Robinette AE, Almonte A, et al. Implementation of preexposure prophylaxis for HIV prevention among men who have sex with men at a New England sexually transmitted diseases clinic. Sex Transm Dis 2016; 43:717–723. [PubMed]
10. Levine K, Maloney KM, Zaslow S, Krakower DS, Grasso C, John BH, et al. ‘Increasing HIV suppression, PrEP use, and STDs in Boston MSM accessing primary care’ (abstract ID 890). 2016 Conference on Retroviruses and Opportunistic Infections (CROI). Boston, MA. February 25, 2016.
11. Gardner ED, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test and treat strategies for prevention of HIV infection. Clin Infect Dis 2011; 52:793–800. [PMC free article] [PubMed]
12. Smith DK, Van Handel M, Wolitski RJ, Stryker JE, Hall I, Prejean J, et al. Vital signs: Estimated percentages and numbers of adults with indications for pre-exposure prophylaxis to prevent HIV acquisition: United States, 2015. MMWR 2015; 64:1291–1295. [PubMed]
13. Centers for Disease Control and Prevention. CDC Fact Sheet: HIV among gay and bisexual men. Atlanta: CDC; 2015.
14. Mayer KH, Ducharme R, Zaller ND, Chan PA, Case P, Abott D, et al. Unprotected sex, underestimated risk, undiagnosed HIV and sexually transmitted diseases among men who have sex with men accessing testing services in a New England bathhouse. J Acquir Immune Defic Syndr 2012; 59:194–198. [PMC free article] [PubMed]
15. Raifman JR, Flynn C, German D. Healthcare provider contact and pre-exposure prophylaxis in Baltimore men who have sex with men. Am J Prev Med 2016. S0749–S3797. [Epub ahead of print]. [PubMed]
16. Elopre L, Kudroff K, Westfall AO, Overton ET, Mugavero MJ. The right people, right places, and right practices: disparities in PrEP access among African American men, women and MSM in the Deep South. J Acquir Immun Defic Syndr 2017; 74:56–59. [PubMed]
17. Mayer KH, Hosek S, Cohen S, Liu A, Pickett J, Warren M, et al. Antiretroviral pre-exposure prophylaxis implementation in the United States: a work in progress. J Int AIDS Soc 2015; 18 suppl 3:19980. [PMC free article] [PubMed]
18. Gengiah TN, Moosa A, Naidoo A, Mansoor LE. Adherence challenges with drugs for preexposure prophylaxis to prevent HIV infection. Int J Clin Pharm 2014; 36:70–85. [PMC free article] [PubMed]
19. Grant RM, Anderson PL, McMahan V, Liu A, Amico KR, Mehrotra M, et al. Uptake of preexposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infect Dis 2014; 14:820–829. [PubMed]
20. Bekker LG, Hughes J, Amico R, Grant R, Roux S, Hendrix C, et al. HPTN 067/ADAPT Cape Town: A comparison of daily and nondaily PrEP dosing in African women. 2015 Conference on Retroviruses and Opportunistic Infections. Seattle, February 23–24, 2015. Abstract 978LB.
21. World Health Organization (WHO). WHO Consultation on PrEP Adherence. Geneva: WHO; 2014.
22. Haberer J, Bangsberg DR, Baeten JM, Curran K, Koechlin F, Amico RK, et al. Defining success with HIV preexposure prophylaxis: a prevention effective adherence paradigm. AIDS 2015; 29:1277–1285. [PMC free article] [PubMed]

Articles from Lippincott Williams & Wilkins Open Access are provided here courtesy of Wolters Kluwer Health