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Promoting PrEP Persistence
The Importance of Understanding Unique Patient Needs to Promote PrEP Persistence

Released: March 22, 2023

Darrell H S Tan
Darrell H S Tan, MD, FRCPC, PhD
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Key Takeaways
  • Reasons for PrEP discontinuation often are unique to the individual and caused by various life circumstances.
  • Understanding personalized patient needs and building trusted relationships is a key component of promoting PrEP retention.
  • Breaking down systemic barriers to PrEP access will allow for expanded access to treatment for all people at risk of contracting HIV. 

Consistent Use Is Key to PrEP Efficacy
Although PrEP uptake in Canada continues to increase, this safe and effective HIV intervention can reach its true public health potential only if users at ongoing risk of contracting HIV maintain consistent use. Unfortunately, not all PrEP use is as persistent as we might hope.

PrEP users may choose to stop treatment for numerous reasons. Many of these motives make good clinical sense and reflect periods of lower HIV risk, such as the beginning of a closed monogamous relationship with an HIV-negative partner or a prolonged period of travel during which sexual exposures will be highly unlikely. However, other reasons for PrEP discontinuation may not align with actual HIV risk and may signal an increased need for patient‒healthcare professional (HCP) engagement.

Reasons for PrEP Discontinuation Often Are Counterintuitive
A striking example of PrEP cessation due to a counterintuitive circumstance was seen in a cohort of young Black men who have sex with men (YBMSM) in Atlanta. This study found that one factor associated with lower persistence on PrEP was the diagnosis of a bacterial sexually transmitted infection (STI), a surprising association that has been corroborated by other studies.

To HCPs, these findings may feel contradictory, given the unambiguous association of syphilis, rectal chlamydia/gonorrhea, and other STIs with incident HIV infection among YBMSM not using PrEP. Indeed, in my own clinical practice, I have had patients tell me they deliberately stopped taking PrEP because of circumstances that suggest a heightened, as opposed to decreased, risk of HIV, such as learning that a regular partner was engaging with more sexual partners than they previously had disclosed. Although this might be confusing to HCPs initially, such scenarios should pique our curiosity about the lived experiences of our patients and inspire us to explore their thoughts and feelings in greater detail.

Digging Deeper Into Personal Reasons for PrEP Discontinuation
In complementary qualitative research, the authors of the Atlanta study found that many patients believed that contracting an STI caused their sex lives to “slow down,” prompting some to stop taking PrEP as part of a deliberate, renewed approach to their sexual practices.

A deeper exploration with one of my patients who stopped taking their pills suggested that their PrEP discontinuation was related to depressive symptoms that had emerged upon learning of their partner’s other relationships. Such scenarios are a reminder of how high-quality PrEP delivery requires adequate time and resources to ensure that we approach each case of PrEP nonpersistence with care.

Improving PrEP Persistence
In many cases of PrEP non-persistence, patients become “lost to follow-up,” and HCPs never have the opportunity to discuss personal reasons for PrEP cessation. Although the specific reasons for discontinuation in this group are, by definition, challenging to capture, studies have documented some commonalities.

Many studies have shown that younger users are less likely than older users to persist on PrEP, emphasizing the need to innovate with new PrEP implementation strategies that appeal to younger generations, such as harnessing text messaging, using online platforms, or employing gamification strategies.

In Canada, online services that provide PrEP to patients recently have become popular, but it remains to be seen if this alternative method of PrEP distribution results in an improvement in care retention.

Historically, PrEP persistence also has been lower among Black PrEP users. Overlapping challenges at the personal (eg, lack of information), community (eg, stigma) and health system (eg, lack of cultural sensitivity) levels likely contribute to this disparity in long-term PrEP use, reflecting ongoing structural racism that calls for deep community engagement in efforts to boost PrEP uptake, adherence, and persistence in marginalized groups. 

Decreasing Financial Barriers to PrEP Access
Finally, one of the most vexing contributors to PrEP non-persistence within the Canadian population may be lack of financial resources. Although PrEP medications are universally accessible with no out-of-pocket expense in some Canadian jurisdictions, they remain only partially publicly insured in others. Many people who enthusiastically initiate PrEP use subsequently drop out of care when their financial circumstances change and they no longer can afford their co-pays or deductibles.

To best support those at risk of PrEP non-persistence, HCPs should encourage efforts to expand access to these medications and be knowledgeable about the existence of compassionate access programs, social assistance, and other mechanisms for PrEP access.

Ultimately, the strategies we use to promote PrEP uptake and persistence at a health system level are similar to those we need to promote PrEP persistence on an individual scale. Key principles include dedicating adequate time and resources to building patient‒HCP relationships, continuing innovations to support diverse users and engage racial and ethnic minoritized communities, and promoting strategies to ensure medication access.

Your Thoughts?
What is your practice setting doing to promote PrEP persistence? Please leave a comment in the discussion box below.