Insurance Coverage, Relationship Status, Other Factors Linked to PrEP Reinitiation

Brian Mustanski, PhD, is a tenured professor of medical social sciences at Northwestern University, founding director of the Institute for Sexual and Gender Minority Health and Wellbeing, and codirector of the NIH Third Coast Center for AIDS Research. In this interview, he reviews findings from a recent study aimed at understanding predictors of preexposure prophylaxis (PrEP) reinitiation among patients who discontinued preventive HIV treatment.

What existing data led you and your coinvestigators to conduct this research?

Daily oral PrEP for reducing HIV transmission is recommended for those at elevated risk, including young gay and bisexual men and transgender women. However, PrEP discontinuation is common, and this may be due to the nature of PrEP, sometimes perceived as a “lifestyle drug” used specifically during periods of increased risk of HIV infection. Studies estimate as many as 62% of daily oral PrEP users discontinue the regimen within the first year following initiation, and youth are particularly likely to discontinue.

While research has begun to examine the reasons for discontinuation, very little research has examined reinitiation after a previous discontinuation. Given most people will not stay on PrEP for the rest of their lives, we cannot simply study factors that influence initiation. Understanding how and why individuals reinitiate PrEP after a prior discontinuation is critical to ensuring the optimal preventive benefit of PrEP during periods of elevated risk for HIV acquisition. We sought to understand existing complexities as people decide to reinitiate PrEP after discontinuation.

Please briefly describe your study and its findings. Were any of the outcomes particularly surprising?

Few studies have examined reinitiation among PrEP discontinuers, which is critical to ensuring optimization of PrEP’s protection. Existing literature suggests PrEP discontinuation is common among young gay and bisexual men and transgender women, but contextual information about PrEP reinitiation is not widely available.

In this study, we sought to understand predictors of reinitiation in a longitudinal sample of PrEP discontinuers. Multilevel structural equation models were used to examine the effects of psychosocial variables on reinitiation. Such variables included time since discontinuation, insurance status, housing instability, relationship agreement and status, partner living with HIV, and condomless anal sex partners. Results indicated that 66.4% (n=168) of total participants (n=253) had 0 reinitiation events, 29.6% (n=75) had 1 reinitiation event and only 4% (n=10) had 2 reinitiation events.

Three broader variables were examined in relation to PrEP re-initiation: (1) variables that may be associated with perceived risk for HIV transmission, (2) socioeconomic variables, and (3) demographics. First, relationship agreements were associated with PrEP reinitiation, indicating that being in an open relationship or being single was associated with a higher likelihood of PrEP reinitiation, relative to being in a monogamous relationship.

Second, insurance status was associated with PrEP reinitiation, suggesting that gaining access through insurance to reduced cost or fully-covered medication, along with accompanying clinical care requirements, may promote PrEP reinitiation. Third, having a main partner who is living with HIV was associated with PrEP reinitiation.

Fourth, bisexual identity was negatively associated with PrEP reinitiation. While little is known about why bisexual individuals have a lower reinitation rate, we suspect they may not perceive themselves to be at risk for HIV transmission during periods when they have primarily cisgender women partners.

Our results were aligned with that of the existing research around PrEP discontinuation and reinitiation, but the larger issue is perceptions of “seasons of risk” may not reflect real risks. Within our study, shifts in PrEP use among participants happened within a short period of time, indicating one’s perception of their risk can change abruptly, but decisions to reinitiate PrEP to coincide with this risk are not always made.

For example, a young person may immediately stop PrEP use when entering a new relationship. If that relationship dissolves after a few months and the participant has condomless sex prior to reinitiating PrEP, then there may be heightened risk for HIV transmission. In this analysis, 5.6% of individuals tested positive for HIV during a follow-up appointment after having discontinued PrEP use, which suggests that periods of nonuse did not necessarily align with a sustained reduction in true risk for HIV transmission. Reinitiation events also do not necessarily mean sustained PrEP use.

What are the possible real-world applications of these findings in clinical practice?

Socioeconomic factors such as the ability to pay out-of-pocket and insurance coverage for PrEP impeded on individuals’ ability to reinitiate PrEP. Interventions should help to mitigate financial barriers that make access and optimal adherence to PrEP difficult for all, especially those experiencing financial hardship.

PrEP initiation appointments should always inform and link users to prescription assistance programs which are used to offset the cost of PrEP. Additionally, users who access PrEP through research studies should also be informed of other ways to obtain PrEP in advance and before the end of their study participation.

Do you and your coinvestigators intend to expand upon this research?

As we do with all of our research, we plan to share these findings with the community to help inform HIV services. We also plan to use these findings to help develop and test novel PrEP programs to encourage young people who discontinue PrEP to reinitiate before they may experience risk of infection in the future.

About Dr Mustanski

Brian Mustanski, PhD, is a tenured professor of medical social sciences at Northwestern University, founding director of the Institute for Sexual and Gender Minority Health and Wellbeing, and codirector of the NIH Third Coast Center for AIDS Research (CFAR).

His research focuses on the health and development of LGBTQ youth and the application of new media and technology to sexual health promotion and HIV prevention. He has been a principal investigator of nearly $60 million in research funding and has published over 300 journal articles in the top 1% of citations in public health and social science.

He is a frequent advisor to federal agencies and other organizations on LGBTQ health and HIV prevention. Some recognition for his work includes being named a William T Grant Scholar and being selected from 1600 nominees for NBC News’s 2017 inaugural list of 30 changemakers and innovators making a positive difference in the LGBTQ community.