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Applying a PrEP Continuum of Care for Men who Have Sex with Men in Atlanta, GA
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Clinical Infectious Disease Sept 2015
Colleen F. Kelley1,2, Erin Kahle2, Aaron Siegler2, Travis Sanchez2, Carlos del Rio1,3, Patrick S. Sullivan2, Eli S. Rosenberg2 1Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine 2Department of Epidemiology, Rollins School of Public Health, Emory University 3Hubert Department of Global Health, Rollins School of Public Health, Emory University
Reductions in HIV incidence with pre-exposure prophylaxis (PrEP) for men who have sex with men (MSM) will require significant coverage of those at risk. We propose a simplified framework, similar to the HIV care continuum, to achieve protection with PrEP as follows: 1. At-risk MSM; 2. Awareness of and willingness to take PrEP; 3. Access to healthcare; 4. Receiving a prescription; and 5. Adhering to effective PrEP. We evaluated the PrEP care continuum on an Atlanta cohort of MSM and projected how many MSM might achieve protection from HIV. Even with optimistic estimates, few Atlanta MSM (15%) are projected to achieve protection from HIV with PrEP given the significant barriers described. Each continuum step represents an important point for intervention that could substantially increase the overall effectiveness of PrEP. In addition, novel strategies for PrEP delivery are needed to achieve the necessary effectiveness for Atlanta MSM at risk of HIV.
Summary: The PrEP care continuum is described and applied to a cohort of Atlanta MSM to demonstrate significant barriers to achieving protection from HIV with PrEP. Novel models of PrEP delivery are needed for MSM at high risk of HIV acquisition.
We have illustrated that even with generous, optimistic estimates, few Atlanta MSM will achieve protection from HIV with PrEP given significant barriers currently in place. With substantial 20% increases at all steps, the potential for increasing overall coverage was improved to 44%, which has been projected to avert nearly 25% of new infections over 10-years.[11] Given the current state of the PrEP care continuum, large, sustained changes are needed to achieve levels of HIV protection that might alter the course of the epidemic. It is also notable that black MSM are less likely to have access to healthcare, to screen as eligible for a PrEP prescription, and to ultimately be protected by PrEP, despite facing HIV incidence rates nearly triple that of white MSM in Atlanta.[6] Therefore, disparities in achieving HIV protection with PrEP, while not statistically significant in our theoretic projections, have the potential to worsen racial disparities in HIV unless concerted effort is taken to enhance access for those most at-risk.
Each step of the proposed continuum represents a critical intervention point that demands immediate attention, particularly in geographic areas that have a large burden of HIV and have been slow to implement PrEP, such as Atlanta. The likelihood to seek PrEP could be fundamentally changed through mass national awareness campaigns. Access to PrEP could entirely shift with changes in policy to make PrEP free for those who are uninsured. The likelihood of appropriately receiving a PrEP prescription could change based on concerted provider training efforts and development of custom algorithms tailored to local epidemics. Last, adherence and efficacy may shift given development and scale-up of new adherence technology, or shifts in PrEP formulations such as a long-acting, injectable PrEP.[39]
However, given the immediate need for intervention in high incidence settings such as among Atlanta MSM, novel strategies for PrEP delivery that circumvent the barriers presented in the PrEP care continuum are needed to achieve the necessary effectiveness for MSM most at risk of HIV. In our opinion, this should include free or low cost open access PrEP programs targeted to those at highest risk. An important first step would be ensuring that PrEP is freely available where at-risk MSM are currently accessing services including STI screening and treatment centers, HIV testing services, and/or other HIV prevention services.

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