Using Client Centered Care to Promote Pre Exposure Prophylaxis Uptake and Adherence and Among Black Men Who Have Sex with Men in 3 U.S. Cities

Background and Purpose:

Among American subgroups, Black men who have sex with men (BMSM) remain at disproportionate risk of HIV acquisition. Comprising less than 0.4% of the U.S. population, they accounted for more than 20% of all new infections in 2013. Identifying effective and innovative methods to deliver effective prevention and halt the epidemic in this key population is an urgent public health priority. HPTN 073 is one of the first studies to evaluate pre-exposure prophylaxis (PrEP) in a US BMSM population.

HPTN-073 Study assessed the initiation, acceptability, safety, and feasibility PrEP for Black men who have sex with men (BMSM) in three US cities.   The HPTN 073 Study utilized a client-centered care coordination (C4) model to support initiation of PrEP as part of comprehensive risk reduction plans individually-tailored for Black men who have sex with men (BMSM) in three US cities.  

Methods: The HPTN 073 Study enrolled 226 HIV-uninfected BMSM in three US cities, including Los Angeles, CA, Washington DC, and Chapel Hill, NC, between August 2013 and September 2014.  All study participants were offered once daily oral FTC/TDF combined with C4, and followed-up for up to 12 months, with scheduled clinical visit at 13 week intervals. At each visit, participants were evaluated for C4 utilization and PrEP acceptance, in addition to side effects, renal toxicity, adherence, risk behavior and HIV seroconversion. 

Results:  Among the total 226 enrolled participants, 178 (79%) participants initiated PrEP. Proportions of self-reported high PrEP adherence (≥90%) ranged between 62% and 71%, while self-reported low PrEP adherence (<50%) ranged between 13% and 19% during weeks 13 through 52. High adherence was associated with age ≥25, higher education, full time employment, no poly drug use and having a primary partner. Conversely, low adherence is associated with younger age, less education, non-fulltime employment, poly drug use, and no primary partner.  Adjusted analysis shows that having a primary partner and no poly drug are highly associated with high adherence, whereas converse is true for low adherence. Among the total 226 enrolled participants, 221 (97%) participants had at least one C4 encounter, with an average encounter length (minutes) 29 (95 %CI 28-30). For those who initiated PrEP, 176 out of 178 (99%) participants had at least one encounter with an average encounter length 31 (95 %CI 29-33). For those who didn’t initiate PrEP, 42 out of 48 (88%) participants had at least one encounter with average an encounter length 32 (95 %CI 27-38).  Compared to those who declined PrEP, participants who initiated PrEP were more likely to use C4 (OR = 12.6; 95% CI: 2.45-64.5, p=0.0024). 

Conclusion and Implications: :  Understanding the contextual factors that support and impede adherence and targeting these in comprehensive intervention packages may maximize PrEP adherence and minimize lower adherence for BMSM.  Client-centered care coordination was acceptable to Black MSM and highly associated with their initiation of PrEP.   Use of a culturally appropriate, theory driven, client-centered approach can support PrEP uptake and adherence within highly vulnerable BMSM populations.