Pre-exposure prophylaxis (PrEP) is a highly effective intervention for preventing HIV infection when taken daily or intermittently before and after sexual activity. Estimates of efficacy have ranged between 40% and 90%. Furthermore, when drug levels are checked, those who have detectable drug levels are estimated to achieve even higher efficacy than the estimates from clinical trials. However, the range in efficacy is evidence of an individual level gap in implementation. Adherence is the Achilles’ heel of PrEP. PrEP users are generally healthy individuals without a disease, and may have lower tolerance for barriers to access, side effects, or stigma associated with the treatment than individuals who accept a treatment for a diagnosed disease. Uptake, persistence on PrEP, and adherence to PrEP are 3 critical components of PrEP implementation that need to be studied. PrEP is supported, at least in its daily form, by the CDC and other major organizations in the field. However, uptake has lagged demand and need. Dawn Smith from the CDC presented data at the Conference of Retroviruses and Opportunistic Infections this year which demonstrated the ratio of PrEP use to PrEP eligibility is low throughout the United States, particularly in the South and in African-Americans. The health consequences of failing to use PrEP are relatively obvious, the United States overall is not making sufficient progress towards reducing HIV diagnoses to eradicate the epidemic. HIV, although highly treatable with life expectancy nearing HIV-uninfected individuals once individuals start antiretroviral therapy, is expensive to treat and antiretroviral therapy does not reach enough individuals, contributing to severe illness and death, as well as lost economic productivity predominantly at the beginning of individuals working life. The gap that I specifically focus on is PrEP uptake in primary care health systems. Specifically, I am interested in population-based interventions that speed and support PrEP uptake via navigation and panel management-based interventions.
Matt - PrEP is a classic implementation science question and I'm glad that you are digging in. I'm at an implementation science meeting in Chicago as I respond to you, and half the meeting is on PrEP. In my opinion the PrEP community is not systematically harnessing lessons learned from implementing treatment. You are well positioned to remedy that! I also suggest that you reach out to Dave Glidden and Dominique Seidman - Dave is thinking of organizing a PrEP think tank / symposium / targeting implementation. Next week's lecture uses PrEP as a case study so looking forward to your thoughts on that.
Great topic!
One could think that at the stage that we are at in terms of HIV knowledge and compared to say 15-20 years, adherence to therapy would not be a problem, even more in the US. However, I can see how this can be a challenging task. Regarding your population, how are these individuals that need PrEP are identified? Are there any factors in common, other than ethnicity, among those who tend not to be adherent to therapy that you can detect as a target?
I am not familiar with this topic, what navigation and panel management-based interventions entail?