Uptake of HIV Pre-Exposure Prophylaxis (PrEP) in a National Cohort of Gay and Bisexual Men in the United States

Abstract

Objectives: The HIV care cascade provides milestones to track the progress of HIV-positive people from seroconversion through viral suppression. We propose a Motivational pre-exposure prophylaxis (PrEP) Cascade involving 5 stages based on the Transtheoretical Model of Change.

Methods: We analyzed data from 995 men in One Thousand Strong, a longitudinal study of a national panel of HIV-negative gay and bisexual men in the United States.

Results: Nearly all (89%) participants were sexually active in the past 3 months and 65% met Centers for Disease Control criteria for PrEP candidacy. Of those identified as appropriate candidates, 53% were Precontemplative (stage 1; unwilling to take or believing they were inappropriate candidates for PrEP) and 23% were in Contemplation (stage 2; willing and self-identified as appropriate candidates). Only 11% were in PrEParation (stage 3; seeing PrEP as accessible and planning to initiate PrEP) and 4% were in PrEP Action (stage 4; prescribed PrEP). Although few of those who were identified as appropriate candidates were on PrEP, nearly all PrEP users (98%) reported adhering to 4 or more doses per week and most (72%) were returning for recommended quarterly medical visits, resulting in 9% of PrEP candidates reaching Maintenance and Adherence (stage 5).

Conclusions: The large majority of participants were appropriate candidates for PrEP, yet fewer than 1 in 10 were using and adherent to PrEP. These findings highlight the need for interventions tailored to address the unique barriers men face at each stage of the cascade, particularly at the earliest stages where the most dramatic losses were identified.

Figure 1

This figure displays a flowchart of the stepped nature of the Motivational PrEP Cascade. The cascade begins with objective identification, which includes HIV testing and an assessment of HIV risk behavior—individuals for whom PrEP is indicated continued into the PrEP cascade whereas individuals for whom it is not indicated should be regularly reassessed and individuals who test HIV-positive should proceed to the HIV Treatment Cascade. Within the PrEP Cascade, individuals can move forwards and backwards from different stages and remain within the stages of the cascade as long as PrEP remains indicated.

Figure 2

This figure displays the geographic distribution of the full One Thousand Strong cohort at the time of baseline enrollment. Participants were targeted to represent the geographic distribution of same-sex households in the census.

Figure 3

The above figure displays the proportion of gay and bisexual men who were classified as being within each stage of the cascade. Unlike Table 1 which displays the proportion who reached each stage of those who reached the former stage, Figure 3 indicates the proportion for whom that was the final stage reached of all those who were objectively identified as PrEP candidates (n = 636).