Journal Article Annotations
2022, 2nd Quarter
Annotations by John A R Grimaldi MD, Mary Ann Cohen MD, FACLP, Kelly Cozza MD, DFAPA, FACLP, Luis Pereira MD
This cross-sectional, chart review- and survey-based study explored reasons for PrEP discontinuation in a sample of mostly men who have sex with men attending an outpatient PrEP clinic in Antwerp, Belgium. Eligibility was defined as having attended more the 2 clinic visits between June 2017 and February 2020. Participants were considered to have discontinued treatment with PrEP if they had not had a clinic visit since October 2019. Chart review and telephone and email outreach were used to determine PrEP status and if available, reasons for PrEP discontinuation. Patients who were unreachable were classified as having discontinued PrEP. The principal finding was that the large majority of participants, 90.3%, remained in care at 12 months. For participants for whom data were available, there were no HIV seroconversions. Those who discontinued PrEP were more likely to be young. The most common reasons for discontinuing were related to reduced self-perceived risk of acquiring HIV: reduced sexual activity due to COVID-19, monogamous relationship, reduced sexual activity not due to COVID-19 and consistent condom use. Side effects, barriers to access, and feeling burdened by required procedures were less commonly reported reasons.
Strength and weaknesses:
Research related to PrEP as a public health intervention has emphasized increasing public and provider awareness and enhancing uptake among eligible persons. This study addresses the less-studied areas of PrEP persistence, reasons for stopping or interrupting PrEP, and degree of HIV risk for persons who stop taking PrEP. The study’s attempt to capture the lived experience of persons taking PrEP is a particular strength. The study has several limitations. Participants were required to have attended more than 2 PrEP clinic visits, which biased results in favor of PrEP continuation. Outreach to participants may have occurred 1-3 years after their last clinic visit, therefore introducing recall bias. Outreach was performed by clinic staff which may have influenced participants to respond in the direction of continuing PrEP or discontinuing for “acceptable” reasons. Additionally, the most common reason given for stopping PrEP was reduced sexual activity related to COVID-19. This is an interesting finding in light of “discontinuation” being defined as no clinic visit since October 30, 2019, many months before the beginning of the pandemic. The study’s location in Belgium and sample of mostly White men who have sex with men makes it poorly generalizable to Black and Hispanic men who have sex with men and women in the US for whom PrEP uptake has been disproportionately low.
Relevance: The role of PrEP has been widely promoted as essential to the campaign to End HIV in the US by 2030. Yet PrEP uptake remains alarmingly low among eligible persons, even more so among Black and Hispanic persons, who are disproportionately diagnosed with HIV. Even though this study was done in Belgium and not easily generalizable to HIV in the US, it provides a generalizable lesson: in a healthcare system with low financial and cultural barriers to accessing care, it is possible to achieve high rates of PrEP persistence. Also, when persons stop taking PrEP, they may do so for “good” reasons that do not heighten their risk of acquiring HIV.
This study utilized patient reported data from the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS), 2017-2019, to compare the percentage of people with HIV (PWH) using drugs and alcohol by geographic region in the US. They found overall rates of substance use as follows: marijuana (MJ) 30%, methamphetamine/crystal (MA) 8%, crack/cocaine 7%, illicit opioids 3%, and injection drug use (IDU) 3%. Binge alcohol use disorders were reported by 32% of the overall cohort, and 16% reported at-risk drinking. Comparison of drug and alcohol use by geographic region yielded the following significant results: PWH in the South were less likely to use any drug, except illicit opioids, when compared to PWH in the West. PWH in the West were more likely to use MA or illicit opioids or report IDU compared to PWH in the Midwest. Crack/cocaine use was more likely in the Northeast compared to the West. At-risk alcohol use and binge drinking were significantly more likely in the Midwest and Northeast and less likely in the South compared to the West. Compared to other clinical sites in the South, Baltimore had lower rates of alcohol use and higher rates of illicit opioid use.
Strength and weaknesses:
This study captures changes that may have occurred in substance use patterns corresponding to evolving variation in policies governing opioid prescribing practices and legalization of marijuana across the US. Recent changes in availability of methamphetamine may also be reflected in the study’s findings. Its large sample size, use of standardized instruments, and diverse racial/ethnic subpopulation are additional strengths. The study is limited by its use of only 7 clinical sites across the US which may not reflect significant variation in substance use within each region. Additionally, the use of self-reported measures may underestimate amount of substance use. The sample of PWH in medical care may not generalize to PWH not in care or undiagnosed.
IDU and non-IDU drug and alcohol use are potent risk factors for HIV acquisition. Similarly, substance use disorders are overrepresented among PWH. The federal plan to end the HIV epidemic relies on concentrating resources on those counties across the US carrying the highest burden of HIV. Understanding behaviors associated with HIV, including current patterns of substance use at a local level, enables the most effective application of these resources.
Between 2018 and 2020, this study recruited 565 men who have sex with men who were receiving HIV primary care at Taipei City Hospital and examined associations among depression, with and without antidepressant treatment, adherence to antiretroviral medications, and health-related quality of life (HRQOL). Fourteen percent of the total sample were classified as depressed. Depressed persons with HIV (PWH) were significantly more likely to be nonadherent to treatment compared to nondepressed participants (22% vs 11%). In depressed PWH who were treated with antidepressant medication, there was no difference in adherence compared to nondepressed PWH. Similarly, depression in PWH was significantly associated with poorer physical, psychological, social, and environmental quality of life compared to nondepressed participants. Those depressed PWH who were treated with antidepressant medication had better HRQOL compared to depressed PWH who were not treated.
Strength and weaknesses:
This study included a measure of HRQOL, which has become an additional component of the World Health Organization’s goal to achieve viral suppression for the large majority of PWH. The study used a standardized instrument to measure adherence to antiretroviral medication. A culture-specific version of the World Health Organization Quality of Life questionnaire was used to assess HRQOL. The sample size used was relatively large. This study’s cross-sectional design limits interpretation of causality between depression, treatment adherence and HRQOL. The use of a self-reported measure of adherence introduces a social desirability bias. Findings may not be generalizable to PWH from non-MSM transmission categories, PWH not receiving care at a large, hospital-based treatment center, or to other countries.
Findings in this study are consistent with previous research that has demonstrated elevated rates of depression in PWH and an association among depression, antiretroviral nonadherence and poor psychosocial functioning. The study strengthens the growing recognition that HIV comprises a syndemic of interacting factors including mental health. Through its inclusion of a patient-centered, quality of life dimension, this study expands the existing emphasis on the population-level goal to end the HIV global pandemic and to improve patient survival.