Extrapolating from the HIV literature, for example, it is possible that not all individuals LTFU from a specific PrEP program are out of care and off anti-retroviral medications, as some will have transferred care elsewhere (Geng et al., 2013). From 2015 to 2019, 6-month retention in PrEP care at SFCC decreased significantly from 66 to 51% ( p-trend < 0.05 using Cochrane-Armitage testing, SFCC unpublished data).įor PrEP programs to design and implement initiatives aimed to improve retention rates, it is critical to better understand the outcomes of individuals who are LTFU from clinic-based PrEP programs. Despite a robust PrEP program providing PrEP to over 1000 patients per year - wherein PrEP counselors follow up with patients 2 weeks after PrEP initiation, before each quarterly PrEP visit, and at 2 weeks and 3 months after any missed quarterly visit - rates of PrEP retention-in-care have declined over time. This has been demonstrated among PrEP cohorts in Los Angeles (Shover et al., 2019) and in Montreal (Greenwald et al., 2019), which respectively observed HIV seroconversion rates of 2.1 and 3.9 per 100 person-years among people who discontinued PrEP versus 0.1 and 0/100 person-years among people who did not.Īt San Francisco City Clinic (SFCC), San Francisco’s only municipal STI (sexually transmitted infection) clinic, PrEP has been offered as part of drop-in sexual health services since 2015. PrEP patients who are lost-to-follow-up (LFTU) are more likely to acquire HIV compared with those retained in care. While PrEP retention rates were relatively high (ranging 69–92%) in clinical trials and demonstration projects, they have been estimated at just 15–62% in non-research settings (Wu et al., 2020). Yet, sub-optimal long-term retention in PrEP care remains a primary challenge to the real-world effectiveness of PrEP (Serota et al., 2018). Pre-exposure prophylaxis (PrEP), typically with daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC), is a highly effective HIV prevention strategy (Fonner et al., 2016 Riddell et al., 2018) and a key component of the Ending the HIV Epidemic initiative in the USA (Giroir, 2020). We were less successful in re-engaging LTFU patients in PrEP care, suggesting that text-messaging may not be the optimal strategy for this purpose. While such information could prove valuable as programs seek to address barriers to PrEP retention, efforts to improve acceptability and increase response rates would be necessary. We learned that text messaging is a possible approach to survey certain PrEP program participants to determine who is truly LTFU and off PrEP, and to better understand reasons for PrEP discontinuation. While 32 participants agreed to be contacted by City clinic staff for PrEP counseling, only 6 were reached by phone and none of the six subsequently restarted PrEP. Free text responses revealed additional concerns regarding risk compensation. Common reasons for stopping PrEP included: COVID-19–related changes in sex life (32.3% of responses), concerns regarding side effects (17.7%), and the need to take a daily pill (8.3%). Forty-two respondents (32.3%) were still on PrEP through another provider while 88 (67.7%) were not. Of 846 eligible survey recipients, 130 responded (overall response rate 15.4%). Multiple-choice survey questions were analyzed quantitatively to determine the proportion of respondents selecting each option free-text responses were analyzed qualitatively using an inductive approach to identify any additional recurring themes. Our goals were to better understand (1) whether our patients remained on PrEP through another provider or source, (2) why patients choose to discontinue PrEP, and (3) whether text-based outreach could successfully re-engage such patients in care. ![]() Using text-messaging, we surveyed San Francisco City Clinic patients who started PrEP from January 2015 to October 2019 and were LTFU by October 1, 2020. We evaluated the benefits and limitations of using text-based outreach to re-engage with LTFU PrEP patients and offer re-initiation of PrEP care. It is critical to understand what happens when PrEP patients are lost-to-follow-up (LTFU) and, where appropriate, attempt to re-engage them in care with the goal of preventing future human immunodeficiency virus (HIV) acquisition.
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