Telehealth effectiveness for pre-exposure prophylaxis delivery in Brazilian public services: the Combine! Study

Abstract

Introduction: Pre-exposure prophylaxis (PrEP) delivery based on user needs can enhance PrEP access and impact. We examined whether telehealth for daily oral PrEP delivery could change the indicators of care related to prophylactic use in five Brazilian public HIV clinics (testing centres, outpatient clinics and infectious disease hospitals).

Methods: Between July 2019 and December 2020, clients on PrEP for at least 6 months could transition to telehealth or stay with in-person follow-up. Clients were clinically monitored until June 2021. A desktop or mobile application was developed, comprising three asynchronous consultations and one annual in-person consultation visit. Predictors influencing telehealth preference and care outcomes were examined. The analysis encompassed intent-to-treat (first choice) and adjustments for sexual practices, schooling, age, duration of PrEP use and PrEP status during the choice period.

Results: Of 470 users, 52% chose telehealth, with the adjusted odds ratio (aOR) increasing over time for PrEP use (aOR for 25-months of use: 4.90; 95% CI: 1.32-18.25), having discontinued PrEP at the time of the choice (aOR: 2.91; 95% CI: 1.40-6.06) and having health insurance (aOR: 1.91; 95% CI: 1.24-2.94) and decreasing for those who reported higher-risk behaviour (aOR for unprotected anal sex: 0.51; 95% CI: 0.29-0.88). After an average follow-up period of 1.6 years (95% CI: 1.5-1.7), the risk of discontinuing PrEP (not having the medication for more than 90 days) was 34% lower with telehealth (adjusted hazard ratio: 0.66; 95% CI: 0.45-0.97). When adjusted by mixed linear regression, no differences in adherence (measured by mean medication possession rate) were found between in-person and telehealth (p = 0.486) or at pre- and post-telehealth follow-ups (p = 0.245). Sexually transmitted infections increased between the pre-follow-up and post-follow-up choices and were not associated with in-person or telehealth (p = 0.528). No HIV infections were observed.

Conclusions: Our findings indicate that telehealth for PrEP delivery can enhance service rationalization and reinforce the prevention cascade. This approach reduces prophylaxis interruptions and is mainly preferred by individuals with lower demands for healthcare services.

Keywords: Brazil; effectiveness; human immunodeficiency virus; pre-exposure prophylaxis; prevention; telehealth.

Figure 1

Risk function adjusted by the Cox model for discontinuation of PrEP after choosing the type of follow‐up.

Figure 2

Estimation of the mean rate of medication possession in the pre‐ and post‐choice periods of the type of clinical follow‐up. Notes: 1. Performed using a mixed linear model 2. Descriptive level of the mixed linear Model (p): in‐person and telehealth follow‐up (0.486); pre‐ and post‐choice time (0.054); Interaction type of follow‐up and time (0.245) 3. Number of observations = 5819, relative to 470 individuals

Figure 3

Estimates of the frequency of STIs (cases/year) by type of chosen follow‐up and for the pre‐ and post‐choice periods. Notes: 1. Performed using generalised estimation equations with negative binomial distribution. 2. Multiple comparisons between Bonferroni correction follow‐ups – Pre (p = 0,772) and Post (p = 0.438). 3. Multiple comparisons between times with Bonferroni correction telehealth (p < 0.001) and in‐person (p < 0.001). 4. Adjustment variables: age, education, partnership, prostitution, active anal sex without condom with casual partner, passive anal sex without condom with casual partner and total number of partners.