PrEP Uptake for HIV Prevention Characterized in Veterans

“PrEP remains unstudied within the VHA,” said study author Puja Van Epps, MD
“PrEP remains unstudied within the VHA,” said study author Puja Van Epps, MD

NEW ORLEANS, LA—The first study to characterize use of pre-exposure prophylaxis (PrEP) for HIV prevention in veterans urges that "further efforts to effectively deliver PrEP to at-risk veterans should be focused in other moderate-to-high HIV prevalence regions," IDWeek attendees were told.

"When taken regularly, PrEP is effective in preventing HIV in the real world setting," the study found.

The Food and Drug Administration approved the once-daily emtricitabine/tenofovir (FTC/TDF) regimen for PrEP in July 2012. Although the Veterans Health Administration (VHA) is the largest single provider of HIV care nationally, “PrEP remains unstudied within the VHA,” reported Puja Van Epps, MD, Geriatric Research Education & Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, and Infectious Diseases and HIV Medicine, Case Western Reserve University, Cleveland, OH.

To characterize the regional and provider patterns of PrEP uptake and its effectiveness in the veteran population, Dr. Van Epps and colleagues queried VHA national patient databases to identify veterans who had FTC/TDF prescriptions initiated between June 2012 and March 2016. Excluded were those with a diagnosis of HIV or chronic hepatitis B prior to the prescription, needle stick injury, or those receiving <30 days of FTC/TDF.

"Nationwide chart review was done to validate the cohort as well as obtain risk factor and provider information," Dr. Van Epps noted.

They identified 826 veterans initiated on FTC/TDF for PrEP, with more than 80% of PrEP starts prescribed by an infectious disease (ID) specialist or with an ID consult. PrEP use varied by VHA region, with the majority of prescriptions clustered in a few cities and regions; notably, 29% of the starts were initiated in California.

“Since 2014, we observed a marked increase in PrEP initiations among veterans nationally,” Dr Van Epps reported.

Among the starts, 6 seroconversions to HIV were found; in 3 of the cases, the mutation was to emtricitabine (M184V) and the patients had sporadic PrEP use. No mutations to tenofovir were detected. The other 3 cases occurred after PrEP was discontinued.

Compared with men who have sex with men or men who have sex with men or women, men who have sex with women and women who have sex with men were more likely to initiate PrEP while in a serodiscordant relationship.

"Provider-initiated PrEP was more likely to follow PEP [post-exposure prophylaxis] therapy, while patient-initiated therapy was more likely to be initiated without known exposure," the investigators found.

Mean age was 41 years (range, 23–77 years). They noted that veterans who received PrEP were older, had more chronic conditions, and were on more chronic medications than those who participated in PrEP clinical trials.

The study showed that within the VHA, both primary care and ID providers prescribe PrEP for at-risk veterans and that a model for hybrid prescribing exists.

"Further studies to explore differences in practice patterns are warranted," the authors concluded. 

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