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No new HIV infections among Kaiser PrEP users, but data shows missed opportunities
Liz Highleyman, 2017-09-07 13:00:00
No new HIV
infections have occurred among nearly 5000 people who started Truvada for pre-exposure prophylaxis
(PrEP) in the Kaiser Permanente Northern California health system, according to
a letter in the 29 July edition of Clinical Infectious Diseases.
were some infections in people who sought PrEP but decided not to take it or
who started but then stopped, indicating
missed opportunities for HIV prevention at various steps of the 'PrEP cascade'.
"Strategies are critically needed to ensure that
patients start, restart or continue PrEP during periods of risk for HIV
acquisition," the researchers concluded.
A growing body
of research has demonstrated that daily or on-demand Truvada (tenofovir disoproxil fumarate/emtricitabine) is highly
effective at preventing HIV when used consistently. Only three cases of PrEP
failure have been reported under those circumstances (see report from CROI 2016, report from HIVR4P 2016 and report from CROI 2017).
Julia Marcus of Harvard Medical School and colleagues
from the Kaiser Permanente Division of Research and Kaiser Permanente San
Francisco Medical Center looked at the risk of PrEP failure defined more
broadly, as occurring at any point along the continuum of care from the time a
person first sought or was referred for PrEP through to ongoing consistent Truvada use.
This study included 7124 people who sought or were referred
for PrEP at Kaiser Permanente Northern California from July 2012 through
February 2017. Most were men who have sex with men.
Kaiser Permanente Northern California, an integrated system that provides comprehensive
medical services to more than 4 million members, has one of the largest PrEP
programmes in the United States. Kaiser researchers previously reported no new HIV infections among its PrEP users,
though they found that sexually transmitted infection rates were high, and they
saw two unusual cases of apparently sexually transmitted hepatitis C
virus in HIV-negative gay men.
Of those seeking or referred for PrEP, 26 members
(0.4%) were diagnosed with HIV during their assessment for PrEP eligibility. Of
the remaining individuals, 70% started PrEP and 30% opted not to do so.
Among the 4991 people who started PrEP, the mean duration
of use, estimated from the time a first Truvada prescription was filled until
the last filled prescription ran out, regardless of gaps in use, was 12.4
months. No new HIV infections occurred during more than 5000 person-years of Truvada use.
Among the 2107 people who did not start PrEP,
22 were later diagnosed with HIV, for an incidence rate of 1.1 per 100
person-years. And among the 1303 people who no longer had any Truvada left at the end of follow-up, 11
were diagnosed with HIV after their last filled prescription ran out, for an
incidence rate of 1.3 per 100 person-years.
"We identified no HIV infections during more than
5,000 person-years of PrEP use, consistent with the high adherence previously
observed in this setting," the researchers wrote.
"However, HIV infections were identified among
individuals who were being assessed for PrEP eligibility (ie, late to access
PrEP), who sought or were referred for PrEP but did not start (ie, failure to
initiate PrEP), or who discontinued PrEP (ie, failure to be retained in PrEP