key: cord-0813216-793zif1g
authors: Spinelli, Matthew A; Laborde, Nicole; Kinley, Patrick; Whitacre, Ryan; Scott, Hyman M; Walker, Nicole; Liu, Albert Y; Gandhi, Monica; Buchbinder, Susan P
title: The importance of PrEP persistence in preventing HIV infections on PrEP
date: 2020-08-26
journal: J Int AIDS Soc
DOI: 10.1002/jia2.25578
sha: 95232d358971e0908bbf1f9d1491b6eadbeff5f9
doc_id: 813216
cord_uid: 793zif1g

nan

We are pleased to learn that our paper's themes resonated with other contexts such as the authors' pre-exposure prophylaxis (PrEP) programme in Sydney, Australia. We are also interested to learn that there is similarly limited awareness and resources supporting PrEP 2-1-1/on-demand dosing [1] in Australia. Anecdotally, several of our PrEP patients are considering transitioning to PrEP 2-1-1 dosing during ongoing shelter-in-place in response to the COVID-19 epidemic, but are worried their clinicians may not support it.

We agree that stigma related to PrEP or sexual behaviour [2] [3] [4] is an important factor that may interfere with PrEP persistence (consistent use of PrEP during periods with potential HIV exposure) [5] . Participants in this analysis did not report stigma related to being a man who has sex with men (MSM) as a factor in their PrEP gaps, but two participants discussed stigma related to the image of PrEP as a medication for people with multiple sexual partners, and at least one participant feared disclosure of her PrEP use to her partner as she felt it might imply she had outside partners [6] .

We agree with the authors that PrEP uptake is an important component of the PrEP cascade, and will be crucial towards meeting global targets to reduce HIV transmission [7, 8] . As the design of this analysis involved a sample of all individuals who had used PrEP at any point in our health system, we were not able to interview individuals who HIV seroconverted and had never used PrEP before. In an analysis within another integrated health system in Northern California, barriers to PrEP use among those who were aware of PrEP prior to HIV diagnosis but never started it included: cost/insurance issues, perceived low risk for HIV acquisition and concerns about being stigmatized if they used PrEP [9] . In San Francisco in 2017, approximately 40% of MSM had used PrEP in the last six months, whereas 50% reported condomless anal sex over the same time period [10] . We, however, found in a prior analysis that the relative risk of PrEP discontinuation is unfortunately increasing over time, potentially because later versus early adopters are more ambivalent about using and remaining on PrEP [11] . As more individuals try PrEP in our jurisdiction and others, we will need to turn our focus towards intervenable factors that can support PrEP persistence. In order to maximize PrEP's prevention efficacy, individuals will need to remain on PrEP with adequate adherence during periods of HIV exposure. We agree that there is no time to waste in addressing potential barriers to implementation of this highly effective, but still underutilized, HIV prevention intervention. 

for HIV in men who have sex with men: an observational cohort study

Reasons why young men who have sex with men report not using HIV Pre-exposure prophylaxis: perceptions of burden, need, and safety

Validation of the HIV pre-exposure prophylaxis stigma scale: performance of Likert and semantic differential scale versions

Experiences of pre-exposure prophylaxis stigma, social support, and information dissemination among black and Latina transgender women who are using pre-exposure prophylaxis

PrEP Persistence is a critical issue in PrEP implementation

Missed opportunities to prevent HIV infections among pre-exposure prophylaxis users: a population-based mixed methods study

Beyond the 90-90-90: refocusing HIV prevention as part of the global HIV response

Interventions to strengthen the HIV prevention cascade: a systematic review of reviews

Barriers to preexposure prophylaxis use among individuals with recently acquired HIV infection in Northern California

San Francisco Department of Public Health HIV Epidemiology Section

Missed visits are associated with future pre-exposure prophylaxis (PrEP) discontinuation among PrEP users in a municipal primary care health network